Clinical Utility of Indocyanine Green Fluorescence in Neonatal Surgery: A Single-Center Study and Systematic Review

Abstract

Introduction

The use of indocyanine green (ICG) fluorescence in neonatal procedures is limited to specific pathologies, with variability in its application, highlighting the need to expand its indications and standardize administration protocols. We present our experience and review of the literature.

Materials and Methods

Prospective assessment (2019–2023) of ICG-navigated neonatal surgeries. Administration routes included intravenous, endoluminal, and intracatheter. ICG dosages were variable according to the indication. The results were prospectively registered, focusing on its ability to achieve the desired goal. A systematic literature review identifying neonatal cases where ICG fluorescence was used for surgical assistance was conducted according to the PRISMA guidelines.

Results

ICG was used in 23 procedures. The average weight was 3.5 kg (SD = 1.4). Surgical procedures were: esophageal atresia repair (eight), intestinal anastomosis (five), Kasai portoenterostomy (five), H-type tracheoesophageal fistula closure (one), diaphragmatic plication (one), omphalocele repair (one) and resection of choledochal cyst (one), lymphatic malformation (one), and pyloric duplication (one). 52.2% were minimally invasive. ICG was useful in 21/23 (91.3%) procedures and was unsuccessful in two cases due to technical difficulties. There were no complications following the ICG injection. Eight studies reporting on 23 neonatal patients were selected for the review. The primary applications of ICG included angiography, cholangiography, lymphography, and visualization of the digestive tract.

Conclusion

To date, this is the largest reported series of ICG-navigated neonatal surgeries. ICG proved to be safe and feasible in this population, allowing the identification of anatomical structures, facilitating decision-making, and minimizing the risk of complications. It is versatile for various procedures and approaches.

Keywords

indocyanine green - fluorescence - neonate - laparoscopy - thoracoscopy

Publikationsverlauf

Eingereicht: 21. Januar 2025

Angenommen: 09. Juni 2025

Accepted Manuscript online:
10. Juni 2025

Artikel online veröffentlicht:
27. Juni 2025

• References

• 1 Guillén G, López-Fernández S, Molino JA, Bueno J, López M. [Pilot experience with indocyanine green navigation in pediatric surgery]. Cir Pediáatr 2019; 32 (03) 121-127
• 2 Shirota C, Hinoki A, Tainaka T. et al. Application of indocyanine green fluorescence imaging navigation in pediatric surgery: a single-center review. J Pediatr Surg Open. 2023; 4: 100075
• 3 García-Hernández C, Cabrera-González H, Carvajal-Figueroa L, Archivaldo-García C, Valero-Mamani RJ, Martinez-Flores RA. Usefulness of indocyanine green fluorescence in laparoscopic resection of choledochal cyst in children. J Pediatr Surg Case Rep 2022; 76: 102129
• 4 Yanagi Y, Yoshimaru K, Matsuura T. et al. The outcome of real-time evaluation of biliary flow using near-infrared fluorescence cholangiography with Indocyanine green in biliary atresia surgery. J Pediatr Surg 2019; 54 (12) 2574-2578
• 5 Sincavage J, Gulack BC, Zamora IJ. Indocyanine green (ICG) fluorescence-enhanced applications in pediatric surgery. Semin Pediatr Surg 2024; 33 (01) 151384
• 6 Esposito C, Settimi A, Del Conte F. et al. Image-guided pediatric surgery using indocyanine green (ICG) fluorescence in laparoscopic and robotic surgery. Front Pediatr 2020; 8: 314
• 7 Breuking EA, van Varsseveld OC, Harms M, Tytgat SHAJ, Hulscher JBF, Ruiterkamp J. Safety and feasibility of indocyanine green fluorescence angiography in pediatric gastrointestinal surgery: a systematic review. J Pediatr Surg 2023; 58 (08) 1534-1542
• 8 Sicard R, Oleru O, Doan J, Seyidova N, Taub PJ. Efficacy and dosing of indocyanine green in pediatric plastic and reconstructive surgery. Microsurgery 2024; 44 (05) e31188
• 9 Urrútia G, Bonfill X. [The PRISMA statement: a step in the improvement of the publications of the Revista Española de Salud Pública]. Rev Esp Salud Publica 2013; 87 (02) 99-102
• 10 Khan HA, Molino JA, Guillén G, López-Fernández S, López M. Laparoscopic repair of duodenal atresia using ministapler: initial experience. Journal of Pediatric Surgery Open. 2023; 2: 100024
• 11 Todani T. Congenital choledochal dilatation: classification, clinical features, and long-term results. J Hep Bil Pancr Surg. 1997; 4: 276-282
• 12 Shirotsuki R, Uchida H, Tanaka Y. et al. Novel thoracoscopic navigation surgery for neonatal chylothorax using indocyanine-green fluorescent lymphography. J Pediatr Surg 2018; 53 (06) 1246-1249
• 13 Li S, Zhao Y, Zhang Y. et al. Indocyanine green localization for laparoscopic duodenal web excision. Photodiagnosis Photodyn Ther 2022; 38: 102842
• 14 Onishi S, Muto M, Yamada K. et al. Feasibility of delayed anastomosis for long gap esophageal atresia in the neonatal period using internal traction and indocyanine green-guided near-infrared fluorescence. Asian J Endosc Surg 2022; 15 (04) 877-881
• 15 Zhao J, Zhang Y, Jin Y. et al. Exploratory application of indocyanine green quantification in biliary atresia observational study. Photodiagnosis Photodyn Ther 2022; 39: 102960
• 16 Wang M, Liao J, Li S, Zhang S, Huang J. Laparoscopic indocyanine green fluorescence imaging technique in rare type II cystic biliary atresia. Photodiagnosis Photodyn Ther 2023; 44: 103846
• 17 Shen Q, Liu X, Pan S, Li T, Zhou J. Effectiveness of indocyanine green fluorescence imaging in resection of hepatoblastoma. Pediatr Surg Int 2023; 39 (01) 181
• 18 Sato J, Yotani N, Shoji K. et al. Necrotizing fasciitis following rapidly deteriorating neonatal omphalitis with good initial presentation. IDCases 2023; 32: e01750
• 19 Li G, Liu Z, Zhang Y. et al. Indocyanine green fluorescence imaging localization: a helpful addition to laparoscopic dissection and division of rectourethral fistulae. Photodiagnosis Photodyn Ther 2023; 42: 103335
• 20 Fox IJ, Wood EH. Indocyanine green: physical and physiologic properties. Proc Staff Meet Mayo Clin 1960; 35: 732-744
• 21 Hirayama Y, Iinuma Y, Yokoyama N. et al. Near-infrared fluorescence cholangiography with indocyanine green for biliary atresia. Real-time imaging during the Kasai procedure: a pilot study. Pediatr Surg Int 2015; 31 (12) 1177-1182
• 22 Haga M, Kato M, Kanno M, Shimizu M, Watanabe S. Lipiodol lymphangiography in a very low birth weight premature infant. J Pediatr Surg Case Rep 2020; 58: 101480
• 23 Hayashida K, Yamakawa S, Shirakami E. Lymphovenous anastomosis for the treatment of persistent congenital chylothorax in a low-birth-weight infant: a case report. Medicine (Baltimore) 2019; 98 (43) e17575
• 24 Mihara M, Hara H, Shibasaki J. et al. Indocyanine green lymphography and lymphaticovenous anastomosis for generalized lymphatic dysplasia with pleural effusion and ascites in neonates. Ann Vasc Surg 2015; 29 (06) 1111-1122
• 25 Shibasaki J, Hara H, Mihara M, Adachi S, Uchida Y, Itani Y. Evaluation of lymphatic dysplasia in patients with congenital pleural effusion and ascites using indocyanine green lymphography. J Pediatr 2014; 164 (05) 1116-1120.e1
• 26 Tan IC, Balaguru D, Rasmussen JC. et al. Investigational lymphatic imaging at the bedside in a pediatric postoperative chylothorax patient. Pediatr Cardiol 2014; 35 (07) 1295-1300
• 27 Kim J, Jang Y, Choi SH. et al. Intraoperative fluorescent ureter visualization in complex laparoscopic or robotic-assisted gynecologic surgery. J Pers Med 2023; 13 (09) 1345
• 28 Slakter JS, Yannuzzi LA, Guyer DR, Sorenson JA, Orlock DA. Indocyanine-green angiography. Curr Opin Ophthalmol 1995; 6 (03) 25-32
• 29 Die X, Cui M, Feng W. et al. Applications of indocyanine greenenhanced fluorescence in the laparoscopic treatment of colonic stricture after necrotizing enterocolitis. BMC Pediatr 2023; 23 (01) 635
• 30 Meisner JW, Kamran A, Staffa SJ. et al. Qualitative features of esophageal fluorescence angiography and anastomotic outcomes in children. J Pediatr Surg 2023; 58 (07) 1359-1367
• 31 Zhao J, Zhao Y, Zhang Y. et al. Preliminary exploration of the efficacy of laparoscopic fluorescence cholangiography (LFC) in the diagnosis of biliary atresia compared with intraoperative cholangiography (IOC). Photodiagnosis Photodyn Ther 2023; 41: 103241
• 32 Shirota C, Hinoki A, Togawa T. et al. Intraoperative indocyanine green fluorescence cholangiography can rule out biliary atresia: a preliminary report. Front Pediatr 2022; 10: 1005879
• 33 Delgado-Miguel C, López-Santamaría M, Hernández-Oliveros F. The role of indocyanine green navigation in choledochal cyst surgery. Indian J Surg 2023; 85: 1272-1274