To Reduce Complications Luigi Boni, MD, FACS Associate Professor of Surgery Department of Surgery - IRCCS Policlinico Hospital University of Milan
The Dream of a Surgeon
Image Guided Surgery
Basic Principles
Indocyanine Green Developed in the Second World War as a dye for photography In 1957 tested at Mayo Clinic for Liver function test Angiography of Retinal Veins ICG it is NOT metabolized in human body 95% binds with human albumin It is rapidly removed from the body by the liver Its half time for healthy liver is few minutes Very high toxic dose (5mg/kg/day)
Intravenous injection of ICG 0,1-0,3 mg/kg ICG binds to plasma proteins and remains in the vascular bed Excitation of ICG fluorescence with near infra-red (NIR at 805 nm) Detection of fluorescence signal at 835 nm with special telescopes Evaluation of the fluorescence signal
Available Systems - Open Surgery FLUOBEAM (Fluoptics, France) Artemis (Quest Medical, NL) Gray scale RGB color Gray scale Gray scale
Available Systems - Laparoscopic Surgery
Available Systems - Robotic Surgery
Karl Storz ICG System
ICG Fluorescent Cholagiography
Biliary Tract Lesions in 2015 in USA 750.000 x 0,3%= 2.250
Can We Accept This Figures? 1400 flight at Heathrow each day x 0,3% 42 Plane Crashes/ Day
Biliary Tract Lesions During Laparoscopic Cholecystectomy
Fluorescence Guided Cholecystectomy
Fluorescence Guided Cholecystectomy
Fluorescence Guided Cholecystectomy
Laparoscopic Cholecystectomy for Acute Cholecystitis
Laparoscopic Cholecystectomy for Acute Cholecystitis
Biliary Leak Identification
ICG Fluorescent Bowel Perfusion
Anastomotic Leaks Facts Esophagectomy: Leaks: 4-25% Colonic Resection: Leaks: 2-7% Leak Mortality: Up to 50% Leak Mortality: Up to 15% Total/Partial Gastrectomy: Leaks: 5-12% Rectal Resection: Leaks: 5-20% Leak Mortality: Up to 20% Leak Mortality: Up to 10% Sleeve Gastrectomy: Leaks: 1-4% Leak Mortality: Up to 5%
Anastomotic Leaks
Blood Supply & Anastomotic Leaks Facts: Techniques to Assess Bowel Perfusion Surgeon s Visual Evaluation Color Bleeding Vessels Pulsation Laser Doppler Ultrasound Oxigen Spectroscopy Polarographic Measurement of Oxygen Tension Hydrogen Gas Clearance Radioisotope Studies Microdialysis Fluorescent Angiography
Anterior Resection
Ischemia Where is the Ischemic Segment????
Ischemia TA-TME
Bowel Perfusion Control : Colorectal
Colonic Perfusion Control
Bowel Perfusion Control for Anterior Resection: Case Match Analysis
Laparoscopic Esophagectomy
Bowel Perfusion Control : Esophageal
Sleeve Gastrectomy
ICG Fluorescent Ureter Identification
Ureter Identification
ICG Fluorescent Lymphnodes Mapping
< Fluorescence Guided Surgery Iliac-Obturatory Lymphadenectomy for Melanoma
Lymph Nodes Mapping in Gastric Cancer The Concept of Lymphatic Basin
< Fluorescence Guided Surgery Lymph Node Mapping in Gastric Cancer
Complete Mesocolic Excision During Right Colectomy For Everyone?
Lymphnode Mapping
Lymphnode Mapping in Rectal Cancer
ICG Fluorescence Guided Liver Resection
Fluorescent Appearance of Liver Tumor
Colorectal Metastases Segment VII Invisible Deep Metastases Segment VI Visible Superficial Metastases
Future Perspective
The Future INDEPENDENT FROM THE DISTANCE LIGHT SOURCE-TARGET DOES NOT REQUIRE A CALIBRATION TOOL ENABLES REPETITIVE INJECTIONS ENABLES REPRODUCIBILITY AND STANDARDIZATION
The Future
The Future
The Future
The Future
The Future
Conclusions ICG Fluorescence Enhanced Surgery is an effective tool to increase visualization during laparoscopic surgery The technique is safe and easy to replicate ICG is virtually harmless Costs effective Multiple and multidisciplinary possible applications Significant possible medico-legal repercussion Fluorescence tumor targeting will be the next revolution in the field of real personalized surgery
SPECIAL THANKS Department of General and Emergency Surgery Policlinico Hospital of Milan University of Milan Minimally Invasive Surgery Research Center University of Insubria