Update Course 2021: ICG IN PED SURG

ICG is an insoluble molecule that rapidly binds to albumin, is near-instantaneously visualized with target tissue, and is removed from circulation by the liver and bile.

ICG can be used with laparoscopy (requiring special camera and optics) or with Da Vinci robotic system using the Firefly system.

In pediatric centers, surgeons perform 10 to 30 cholecystectomies per year compared to 100 to 300 per year in adult centers, resulting in a longer learning curve.

ICG preparation involves diluting a 25 mg/4 ml vial with 10 ml of sterile water, then injecting 6 ml intravenously for cholecystectomy.

ICG technology allows surgeons to reduce complications in cholecystectomy to near zero by providing clear visualization of biliary anatomy.

The new Rubina ICG system allows visualization in color with the biliary tree appearing green, compared to older systems that display black and white images.

ICG technology has been adopted routinely for all cholecystectomy cases at the speaker's center.

For cholecystectomy, ICG must be injected 12 to 15 hours pre-operatively (the day before surgery) to allow secretion into bile juice for selective biliary tree visualization.

If ICG is injected intraoperatively for cholecystectomy, the liver takes up the dye and appears green, making it difficult to identify the gallbladder.

For all ICG indications except cholecystectomy (kidney, lymphomas, varicocele), the product is injected intraoperatively.

For elective cholecystectomy cases, patients are hospitalized the day before surgery in the afternoon for ICG injection if surgery is scheduled early the next morning.

In partial nephrectomy for duplex kidney, ICG is injected three times: via ureteral catheter to identify the normal ureter, intravenously to visualize kidney vascularity, and intravenously post-clipping to identify the devascularization line.

In duplex kidney with reflux, the two ureters are attached to each other, and ICG injection via catheter allows identification of the normal ureter that must be preserved.

For partial nephrectomy, 2 ml of ICG solution is injected intravenously to visualize kidney vascularization.

In varicocele repair using Palomo technique (ligating the spermatic bundle), postoperative hydrocele occurs in approximately 20% of cases due to lymphatic vessel ligation.

The spermatic bundle contains three to four lymphatic vessels.

Intratesticular injection of 2 ml ICG solution allows intraoperative fluorescence lymphography to identify and preserve lymphatic vessels during varicocele repair.

In a series of more than 150 varicocele patients using ICG lymphatic identification, there were zero cases of postoperative hydrocele.

The Da Vinci XI robot with Firefly system can be used for ICG fluorescence imaging.

The ICG vial can be used for six hours after preparation.

Additional ICG applications include lymphoma node identification, tumor visualization, and checking vascularization of anastomoses.

There is no maximum dose limit for ICG; it is secreted by bile juice and has been used extensively in adult surgery for over five years without dose-related adverse effects.

Jack Marescaux at IRCAD performed extensive studies on ICG use in cholecystectomy in adult surgery more than five years ago.