title: Superselective intra-arterial hepatic injection of indocyanine green (ICG) for fluorescence image-guided segmental positive staining: experimental proof of the concept.
abstract: Intraoperative liver segmentation can be obtained by means of percutaneous intra-portal injection of a fluorophore and illumination with a near-infrared light source. However, the percutaneous approach is challenging in the minimally invasive setting. We aimed to evaluate the feasibility of fluorescence liver segmentation by superselective intra-hepatic arterial injection of indocyanine green (ICG).
  
  
  
  Eight pigs (mean weight: 26.01 ± 5.21 kg) were involved. Procedures were performed in a hybrid experimental operative suite equipped with the Artis Zeego®, multiaxis robotic angiography system. A pneumoperitoneum was established and four laparoscopic ports were introduced. The celiac trunk was catheterized, and a microcatheter was advanced into different segmental hepatic artery branches. A near-infrared laparoscope (D-Light P, Karl Storz) was used to detect the fluorescent signal. To assess the correspondence between arterial-based fluorescence demarcation and liver volume, metallic markers were placed along the fluorescent border, followed by a 3D CT-scanning, after injecting intra-arterial radiological contrast (n = 3). To assess the correspondence between arterial and portal supplies, percutaneous intra-portal angiography and intra-arterial angiography were performed simultaneously (n = 1).
  
  
  
  Bright fluorescence signal enhancing the demarcation of target segments was obtained from 0.1 mg/mL, in matter of seconds. Correspondence between the volume of hepatic segments and arterial territories was confirmed by CT angiography. Higher background fluorescence noise was found after positive staining by intra-portal ICG injection, due to parenchymal accumulation and porto-systemic shunting.
  
  
  
  Intra-hepatic arterial ICG injection, rapidly highlights hepatic target segment borders, with a better signal-to-background ratio as compared to portal vein injection, in the experimental setting.
authors: IRCAD, Research Institute Against Cancer of the Digestive System, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France. michele.diana@ircad.fr.|IHU-Strasbourg, Institute of Image-Guided Surgery, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France. michele.diana@ircad.fr.
authors: Michele
authors: 0000-0002-1390-8486
authors: M
authors: Diana
authors: IRCAD, Research Institute Against Cancer of the Digestive System, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France.|Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan.
authors: Yu-Yin
authors: YY
authors: Liu
authors: Interventional Radiology Department, University Hospital of Strasbourg, Strasbourg Cedex, France.
authors: Raoul
authors: R
authors: Pop
authors: IHU-Strasbourg, Institute of Image-Guided Surgery, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France.|Department of Surgery, Seoul National University Hospital, Seoul, Korea.
authors: Seong-Ho
authors: SH
authors: Kong
authors: IHU-Strasbourg, Institute of Image-Guided Surgery, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France.
authors: Andras
authors: A
authors: Legnèr
authors: Interventional Radiology Department, University Hospital of Strasbourg, Strasbourg Cedex, France.
authors: Remy
authors: R
authors: Beaujeux
authors: IHU-Strasbourg, Institute of Image-Guided Surgery, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France.|Department of General and Digestive Surgery, University Hospital of Strasbourg, Strasbourg Cedex, France.
authors: Patrick
authors: P
authors: Pessaux
authors: IRCAD, Research Institute Against Cancer of the Digestive System, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France.|IHU-Strasbourg, Institute of Image-Guided Surgery, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France.
authors: Luc
authors: L
authors: Soler
authors: Department of General and Digestive Surgery, University Hospital of Strasbourg, Strasbourg Cedex, France.
authors: Didier
authors: D
authors: Mutter
authors: IRCAD, Research Institute Against Cancer of the Digestive System, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France.
authors: Bernard
authors: B
authors: Dallemagne
authors: IRCAD, Research Institute Against Cancer of the Digestive System, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France.|IHU-Strasbourg, Institute of Image-Guided Surgery, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France.
authors: Jacques
authors: J
authors: Marescaux
mesh_terms: D000792:Angiography / Q000379:methods*; D000818:Animals; D004396:Coloring Agents; D005240:Feasibility Studies; D005456:Fluorescent Dyes; D006499:Hepatic Artery / Q000000981:diagnostic imaging*; D007208:Indocyanine Green; D007259:Infrared Rays; D007269:Injections, Intra-Arterial; D007430:Intraoperative Care / Q000379:methods; D008099:Liver / Q000098:blood supply / Q000000981:diagnostic imaging*; D061848:Optical Imaging / Q000379:methods*; D011169:Portal Vein; D013194:Staining and Labeling; D034421:Sus scrofa; D013552:Swine
chemical_list: D004396:Coloring Agents; D005456:Fluorescent Dyes; D007208:Indocyanine Green
keywords: Fluorescence-guided surgery; Hepatic segmentation; Image-guided surgery; Indocyanine green (ICG); Intra-arterial ICG injection; Laparoscopic liver surgery; Positive staining