title: Real-time Intraoperative Fluorescent Lymphography: A New Technique for Lymphatic Sparing Surgery.
abstract: BACKGROUND
  Many surgical procedures can produce persistent lymphorrhea, lymphoceles, and lymphedema after lymph node and lymph vessel damage. Appropriate visualization of the lymphatic system is challenging. Indocyanine green (ICG) is a well-known nontoxic dye for lymphatic flow evaluation. ICG fluorescence-guided lymphography has emerged as a promising technique for intraoperative lymphatic mapping.
  
  
  OBJECTIVE
  Our goal was to develop a high spatial resolution, real-time intraoperative imaging technique to avoid or recognize early deep lymphatic vessel damage.
  
  
  METHODS
  We intraoperatively performed ICG fluorescence-guided lymphography during a kidney transplant. ICG was injected in the subcutaneous tissue of the patient's groin in the Scarpa's triangle. A dedicated laparoscopic high-definition camera system was used.
  
  
  RESULTS
  Soon after ICG injection, the lymphatic vessels were identified in the abdominal retroperitoneal compartment as fluorescent linear structures running side by side to the iliac vessels. Surgical dissection was therefore performed, avoiding iatrogenic damage to major lymphatic structures. Another ICG injection at the end of the procedure confirmed that the lymphatic vessels were intact without lymph spread.
  
  
  CONCLUSIONS
  Intraoperative lymphatic mapping with an ICG fluorescence-sensitive camera system is a safe and feasible procedure. ICG real-time fluorescence lymphography can be used to avoid or recognize early deep lymphatic vessel damage and reduce postoperative complications related to the lymphatic system.
authors.affiliation: General and Transplant Surgery Department, Insubria University, Varese, Italy. Electronic address: giuseppe.ietto@gmail.com.
authors.forename: G
authors.initials: G
authors.lastname: Ietto
authors.affiliation: General Surgery Department, Insubria University, Varese, Italy.
authors.forename: F
authors.initials: F
authors.lastname: Amico
authors.affiliation: General and Transplant Surgery Department, Insubria University, Varese, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Soldini
authors.affiliation: General and Transplant Surgery Department, Insubria University, Varese, Italy.
authors.forename: C
authors.initials: C
authors.lastname: Chiappa
authors.affiliation: General and Transplant Surgery Department, Insubria University, Varese, Italy.
authors.forename: M
authors.initials: M
authors.lastname: Franchin
authors.affiliation: General and Transplant Surgery Department, Insubria University, Varese, Italy.
authors.forename: D
authors.initials: D
authors.lastname: Iovino
authors.affiliation: General and Transplant Surgery Department, Insubria University, Varese, Italy.
authors.forename: A
authors.initials: A
authors.lastname: Romanzi
authors.affiliation: Urology Department, Insubria University, Varese, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Saredi
authors.affiliation: General Surgery Department, Insubria University, Varese, Italy.
authors.forename: E
authors.initials: E
authors.lastname: Cassinotti
authors.affiliation: General Surgery Department, Insubria University, Varese, Italy.
authors.forename: L
authors.initials: L
authors.lastname: Boni
authors.affiliation: Vascular Surgery Department, Insubria University, Varese, Italy.
authors.forename: M
authors.initials: M
authors.lastname: Tozzi
authors.affiliation: General and Transplant Surgery Department, Insubria University, Varese, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Carcano
mesh_terms: D000368:Aged; D004396:Coloring Agents; D004210:Dissection / Q000009:adverse effects; D005260:Female; D005453:Fluorescence; D006801:Humans; D007208:Indocyanine Green; D016030:Kidney Transplantation / Q000379:methods*; D008198:Lymph Nodes / Q000000981:diagnostic imaging; D008206:Lymphatic Diseases / Q000000981:diagnostic imaging / Q000517:prevention & control; D042601:Lymphatic Vessels / Q000000981:diagnostic imaging / Q000601:surgery; D008209:Lymphedema / Q000000981:diagnostic imaging / Q000209:etiology; D008220:Lymphography / Q000379:methods; D008875:Middle Aged; D059351:Organ Sparing Treatments / Q000379:methods*; D011183:Postoperative Complications / Q000517:prevention & control; D025321:Surgery, Computer-Assisted / Q000379:methods
chemical_list: D004396:Coloring Agents; D007208:Indocyanine Green