This work was supported by the National Natural Science Foundation of China (grant number 82272105), Guangdong Basic and Applied Basic Research Foundation (grant number 2022A1515011244, 2023A1515011521, 2023A1515010475), Medical Scientific Research Foundation of Guangdong Province of China (A2017421, 2016116212141586).

This research was conducted in compliance with the guidelines of the human research ethics committee of the Fifth Affiliated Hospital of Sun Yat-sen University. Written informed consent was obtained from the patient for participation in this study. The criteria for complex laparoscopic cholecystectomy (LC) included: gallbladder wall edema with thickening &#8805;4 mm; gangrenous cholecystitis with or without perforation; a history of upper abdominal surgery; impacted stones in the gallbladder neck; Mirizzi syndrome or variations in the extrahepatic bile duct; and cases requiring transcystic common bile duct exploration. Details of the reagents and equipment used are provided in the Table of Materials.
1. Fluorescence imaging preparation and patient positioning
<ol>
	<li>Administer 0.25 mg of ICG via a peripheral vein injection 45 min before the surgery. 
	NOTE: Dissolve 1 vial of ICG (25 mg) in 10 mL of normal saline. Inject 1 mL of the solution into 100 mL of normal saline for dilution. Administer 10 mL of the diluted solution via intravenous injection 45 min before the surgery.</li>
	<li>Set up the DPM-I fluorescence system, a dual-channel image-guided device, to operate in white-light (380-665 nm) and near-infrared (810-1200 nm) spectrums.</li>
	<li>Position the patient in a supine position. After inducing general anesthesia (following institutionally approved protocols) and completing all safety procedures (hood, sterile gloves, and sterile scrub), create a sterile field. Perform trocar insertion using a four-port method15.</li>
</ol>
2. Fluorescence-guided visualization and identification of biliary structures
<ol>
	<li>Switch to fluorescence mode to locate the bile ducts. 
	NOTE: In fluorescence mode, the stained bile duct structure may be directly visible or revealed after simple separation of encysted fat tissue (Figure 1A).</li>
	<li>Follow the fluorescence navigation to carefully dissect and isolate the cystic duct (CD) and cystic artery (CA) using a cautery hook to achieve the critical view of safety, also known as Calot&#39;s Triangle. 
	NOTE: In fluorescence mode, the CD exhibits a fluorescent signal, while the CA does not show any fluorescent signal.</li>
	<li>Apply Hem-O-lock clips to both the CD and CA after identifying and distinguishing the bile ducts. Place two clips proximally and one distally on the CD. Place one clip proximally and one clip distally on the CA. 
	NOTE: Identify the CD-common bile duct (CBD) junction carefully to prevent inadvertent injury to the CBD.</li>
</ol>
3. Removal of gallbladder
<ol>
	<li>Dissect the gallbladder from its fossa, divide the cystic duct (CD) and cystic artery (CA) between the clips using scissors, and place the gallbladder in an extraction bag.</li>
	<li>Employ white-light mode to detect any bleeding and switch to fluorescence mode to confirm the absence of bile leakage upon completion of the cholecystectomy.</li>
	<li>Remove the gallbladder from the abdominal cavity, place a drainage tube at the gallbladder fossa, and close the abdomen using 4-0 polyglactin. Suture the skin with a 3-0 non-absorbable suture. 
	NOTE: Cut the CD only after confirming there is a single duct entering the gallbladder, especially in cases of biliary anatomy variations such as a right accessory hepatic duct.</li>
</ol>
4. Postoperative monitoring and management
<ol>
	<li>Review inflammatory markers postoperatively.</li>
	<li>Remove the abdominal drainage tube when the drainage is clear and less than 50 mL per day.</li>
	<li>Administer prophylactic antibiotics as needed based on the patient&#39;s clinical status and surgeon&#39;s recommendation.</li>
	<li>Monitor the patient for signs of infection, including fever, redness, or swelling at the surgical site.</li>
	<li>Schedule a follow-up consultation within 7-10 days to assess recovery.</li>
</ol>

<ol>
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The authors declare that they have no conflicts of interest to disclose.

Laparoscopic cholecystectomy (LC) has long been regarded as the gold standard treatment for cholelithiasis and cholecystitis. However, conventional surgical approaches often pose significant challenges in cases involving acute inflammation, gangrene, perforation, and anatomical variations-collectively referred to as difficult gallbladders16. These challenging conditions significantly increase the risks of bile duct injury (BDI) and cystic artery (CA) injury.
BDI is one of the most severe complications associated with LC, often resulting from the misidentification of the cystic duct (CD) and common bile duct (CBD)17. The key to preventing BDI lies in the precise identification of the CD-CBD junction, making the visualization of biliary tracts essential. Traditional intraoperative visualization techniques (IVT), such as cholangiography, ultrasound, and choledochoscopy, were initially developed for this purpose. However, their adoption was hindered by concerns over radiation exposure, a notable margin of error, and cumbersome procedures5,18.
Near-infrared fluorescence (NIRF) is a newly developed intraoperative visualization technique (IVT) that offers numerous advantages across a broad range of hepatobiliary surgeries. These include detecting lesions in primary liver cancer19, identifying liver metastases20, aiding in liver transplantation procedures21, visualizing biliary tracts22, detecting bile leakage23, and applications in pediatric and robotic surgeries24. Indocyanine green (ICG), excreted through the biliary tract, provides a natural advantage in hepatobiliary surgeries.
During laparoscopic cholecystectomy (LC), NIRF provides clear and real-time visualization of bile ducts, effectively preventing unnecessary injuries to biliary structures. Most importantly, NIRF is easy to implement and operate. NIRF-guided LC is a straightforward enhancement to conventional LC procedures, requiring only the preoperative intravenous administration of ICG as an additional step. This technique does not affect the overall surgical process, causes no additional trauma, and allows seamless switching between white-light and fluorescence modes.
The efficacy of intraoperative fluorescence imaging can be influenced by several factors. First, the administration route of ICG injection plays a crucial role. ICG can be administered through preoperative intravenous injection or intraoperative direct gallbladder injection. While direct gallbladder injection is cumbersome, invasive, and does not provide complete visualization of extrahepatic bile ducts (e.g., the common hepatic duct), preoperative intravenous administration is currently the preferred method25,26. Second, the timing and dosage of ICG injection are critical determinants of fluorescence imaging quality, as they affect the intensity of bile duct visualization and liver background interference12,27. The ideal imaging outcome ensures clear visualization of bile ducts with minimal liver background fluorescence (Figure 1B). Third, conducting fluorescence imaging too late after ICG administration may result in insufficient bile duct fluorescence intensity, hindering the identification of anatomical structures (Figure 1C). Finally, excessively late injection can lead to high liver fluorescence and insufficient bile duct fluorescence, limiting its utility in emergency LC scenarios (Figure 1D).
The optimal timing and dosage of indocyanine green (ICG) injection remain under investigation12,28,29,30,31. After extensive research, the timing of 30-45 min preoperatively and a dosage of 0.25 mg has been identified as optimal for achieving satisfactory fluorescence visualization. It is important to note that these results were obtained using the fluorescence device employed at our center (DPM-I fluorescence system). The optimal timing and dosage of ICG may vary depending on the specific fluorescence system used. This shortened injection time has the potential to enable effective use of ICG in emergency laparoscopic cholecystectomy (LC) procedures. When the thickness of the bile duct wall and the overlying fat layer exceeds 1 cm, the fluorescence signal is significantly weakened or may even disappear. To improve fluorescence imaging, the surface fat tissue can be removed, and the bile duct stretched to thin its wall. The impact of bile duct obstruction on fluorescence imaging varies depending on the location of the obstruction. Obstruction at the hepatic hilum may cause strong fluorescence signals in the liver background but a complete lack of imaging in the extrahepatic bile ducts. Conversely, obstruction of the cystic duct (CD) or common bile duct (CBD) may result in no imaging of the obstructed bile duct segment. This article provides detailed steps for performing fluorescence-guided difficult LC as practiced at our center and summarizes the factors influencing fluorescence imaging. The fluorescence navigation technique has been routinely used at our center, achieving a 91% success rate with satisfying imaging outcomes.
Fluorescence navigation employs ICG as its fluorescent dye. ICG has no toxic side effects or allergic reactions when used at concentrations below 2.0 mg/kg, indicating that the required dosage for intraoperative fluorescence navigation (0.25 mg) is well within the safe range. In conclusion, fluorescence navigation is a safe and effective technique that provides crucial assistance in identifying and distinguishing key structures during surgery. In difficult LC procedures, fluorescence navigation significantly improves precision and reduces the risk of iatrogenic damage. It holds great promise for future clinical applications.

Approximately 20% of adults worldwide are affected by biliary stones, which can lead to acute cholecystitis -- a painful, rapidly progressing, and potentially life-threatening condition1. Timely surgical intervention is imperative for patients with cholecystitis. Laparoscopic cholecystectomy (LC) has become widely accepted as the standard treatment for this condition.
However, conventional surgical approaches may present significant challenges in complex cases. Severe inflammation or adhesions can render biliary tracts indistinct, increasing the risk of inadvertent injury to bile ducts or arteries2. Bile duct injury (BDI) is one of the most severe and common complications in these complex LC procedures. It often results in irreversible, lifelong consequences and, in severe cases, fatal outcomes3. Precise identification of critical biliary structures, such as Calot&#39;s triangle, is essential for facilitating surgical procedures and minimizing potential damage4.
Traditional intraoperative visualization techniques (IVT) integrate cholangiography, ultrasound, and choledochoscopy, enabling real-time monitoring of biliary tracts. However, concerns such as radiation exposure, a notable margin of error5, and cumbersome procedures have hindered the widespread adoption of IVT.
Near-infrared fluorescence (NIRF) is a cutting-edge technique that allows easy switching between fluorescence and white-light modes through a single laparoscope, enabling real-time visualization of biliary tracts during surgery. This technique offers high sensitivity, specificity, and tissue penetration capabilities6. NIRF can effectively prevent bile duct injury (BDI) during laparoscopic cholecystectomy (LC), particularly in complex cases involving severe inflammation or adhesions7.
Compared to traditional IVT, NIRF is easier to implement, provides clearer visualization of biliary tracts, and does not cause additional trauma8,9,10. Its fluorescent dye, indocyanine green (ICG), has been proven safe for human use by the Food and Drug Administration11. ICG is typically injected intravenously before surgery; however, the timing and dosage of ICG injection remain uncertain12,13. These factors are critical determinants of high-quality fluorescence imaging. Optimal ICG performance achieves a strong fluorescence signal in the bile ducts while minimizing background fluorescence from liver tissue14.
Through extensive exploration, we have identified the optimal timing and dosage of ICG injection as 0.25 mg administered 45 min preoperatively. This study aims to demonstrate the imaging effects of this timing and dosage in various complex surgical scenarios.

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	<tbody>
		<tr>
			<td>3-0 MERSILK</td>
			<td>JOHNSON MEDICAL (CHINA) LTD.&#160;</td>
			<td>SA84G</td>
			<td>The Suture Material</td>
		</tr>
		<tr>
			<td>4-0 Coated VICRYL</td>
			<td>ETHICON</td>
			<td>VCP310</td>
			<td>The Suture Material</td>
		</tr>
		<tr>
			<td>Endoscopic Fluorescence Imaging System</td>
			<td>ZHUHAI DI PU MEDICAL TECHNOLOGY CO., LTD.&#160;</td>
			<td>H380022041YF</td>
			<td>Fluorescence Laparoscope Equipment</td>
		</tr>
		<tr>
			<td>Hem-O-lock Clips</td>
			<td>SINOLINKS MEDICAL INNOVOATION, INC.</td>
			<td>B240714</td>
			<td>Hem-O-lock Clips</td>
		</tr>
		<tr>
			<td>Indocyanine Green for Injection</td>
			<td>DANDONG YICHUANG PHARMACEUTICAL CO., LTD.&#160;</td>
			<td>H20055881</td>
			<td>Fluorescence Dye</td>
		</tr>
	</tbody>
</table>

the role of indocyanine green fluorescence in complex laparoscopic cholecystectomy navigation

Laparoscopic cholecystectomy (LC) is the gold-standard treatment for cholelithiasis and cholecystitis. In difficult cases with severe inflammation and adhesions, the risk of bile duct injury (BDI) is significantly higher. Precise identification of anatomical biliary structures is essential to prevent such injuries. Conventional intraoperative visualization techniques (IVT) have limited clinical application due to their complexity, increased trauma, and high error rates. Near-infrared fluorescence (NIRF) imaging, utilizing indocyanine green (ICG) as a fluorescent dye, has emerged as an innovative IVT technique. It is increasingly recognized as a feasible, safe, and effective approach for LC. However, the efficacy of NIRF in difficult LC procedures remains unclear, and the optimal timing and dosage of ICG administration are yet to be established. This article outlines the main steps for performing fluorescence-guided difficult LC in a patient with acute gangrenous cholecystitis and evaluates the imaging effects of NIRF in various scenarios. The patient was positioned supine, with four trocars placed. Upon switching to fluorescence mode, the fluorescently labeled bile ducts were readily identified. Following fluorescence guidance, Calot's triangle was carefully dissected. The cystic duct (CD) and cystic artery (CA) were individually identified and clipped before the gallbladder was extracted. Finally, the surgical field was inspected in fluorescence mode to detect bile leakage. With satisfactory ICG imaging and a smooth procedure, the patient's postoperative recovery was uneventful. NIRF is a safe and effective technology that shows great promise for future clinical applications.

Following the surgical procedure outlined in the protocol (Figure 2), fluorescence-guided laparoscopic cholecystectomy (LC) was successfully performed in three patients with difficult gallbladders. There were no conversions to open surgery and no occurrences of bile duct injury (BDI) during the procedure. No bile leakage was observed in fluorescence mode, as demonstrated in the accompanying video. The intraoperative and postoperative outcomes are summarized in Table 1.
Between April and August 2024, a total of 70 cases of fluorescence-guided LC were recorded, with demographic data presented in Table 2. Among these, 91% (64/70) exhibited satisfactory fluorescence imaging, with all bile ducts clearly visualized, strong biliary fluorescence signals, and minimal liver background interference. Three cases failed to demonstrate fluorescence imaging of the extrahepatic bile ducts. This was attributed to common hepatic duct obstruction. Additionally, three cases showed suboptimal fluorescence imaging: two were attributed to early injection of indocyanine green (ICG), and one was due to cystic duct (CD) obstruction.
There were no conversions to open surgery, no bile duct injuries during the procedures, and no postoperative bile leakage, as confirmed through drainage observation. Compared to conventional white-light LC, ICG fluorescence imaging offers the following advantages: (1) Real-time navigation of bile ducts, enhancing surgeons&#39; confidence; (2) Early detection of variant bile ducts; (3) Accurate identification of the CD-common bile duct (CBD) junction, reducing the incidence of BDI; (4) Differentiation between the CD and cystic artery (CA), preventing CA injury; (5) Timely identification of bile leakage. In conclusion, ICG fluorescence navigation makes LC faster, safer, and more precise.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/67562/67562fig01.jpg" /> 
Figure 1: Fluorescence imaging. (A) In fluorescence mode, the stained bile duct is directly observed. (B) Appropriate ICG administration: The biliary fluorescence signal is strong, with bright contrast, while background liver fluorescence is weak. (C) Early injection of ICG: The fluorescence intensity of the bile ducts is insufficient to identify anatomical structures. (D) Late injection of ICG: The liver shows high fluorescence, but the bile ducts do not contain sufficient ICG for adequate visibility. <a href="https://www.jove.com/files/ftp_upload/67562/67562fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/67562/67562fig02.jpg" /> 
Figure 2: Surgery procedure. (A) Intravenous injection of ICG prior to surgery. (B) Pulling the gallbladder upwards to expose Calot&#39;s triangle. (C) Switching to fluorescence mode allows visualization of the bile duct. (D) Following fluorescence navigation to dissect Calot&#39;s triangle. (E) Cleaning the fat tissue from Calot&#39;s triangle reveals a clear visualization of the CHD and CBD. The CD and gallbladder are not visualized, suggesting a stone obstruction at the opening of the CD. (F) After pushing the impacted stone toward the gallbladder, the CD becomes visible. (G) Clamping the CD. (H) After removal of the gallbladder, switching to fluorescence mode detects any bile leakage. <a href="https://www.jove.com/files/ftp_upload/67562/67562fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Variable</td>
			<td colspan="3">Outcomes</td>
		</tr>
		<tr>
			<td>Patients</td>
			<td>First</td>
			<td>Second</td>
			<td>Third</td>
		</tr>
		<tr>
			<td>Operative time (min)</td>
			<td>65</td>
			<td>65</td>
			<td>45</td>
		</tr>
		<tr>
			<td>Conversion to open</td>
			<td>NO</td>
			<td>NO</td>
			<td>NO</td>
		</tr>
		<tr>
			<td>Blood loss (mL)</td>
			<td>20</td>
			<td>20</td>
			<td>10</td>
		</tr>
		<tr>
			<td>BDI</td>
			<td>NO</td>
			<td>NO</td>
			<td>NO</td>
		</tr>
		<tr>
			<td>CA injury</td>
			<td>NO</td>
			<td>NO</td>
			<td>NO</td>
		</tr>
		<tr>
			<td>Postoperative hospital stay (days)</td>
			<td>4</td>
			<td>4</td>
			<td>3</td>
		</tr>
		<tr>
			<td>Drainage duration (days)</td>
			<td>4</td>
			<td>3</td>
			<td>2</td>
		</tr>
		<tr>
			<td>Complications</td>
			<td colspan="3"></td>
		</tr>
		<tr>
			<td>Bile leakage</td>
			<td>NO</td>
			<td>NO</td>
			<td>NO</td>
		</tr>
		<tr>
			<td>Abdominal pain</td>
			<td>NO</td>
			<td>NO</td>
			<td>NO</td>
		</tr>
		<tr>
			<td>Infection</td>
			<td>NO</td>
			<td>NO</td>
			<td>NO</td>
		</tr>
		<tr>
			<td>Transferred to the ICU</td>
			<td>NO</td>
			<td>NO</td>
			<td>NO</td>
		</tr>
		<tr>
			<td>Pathological diagnosis</td>
			<td>Acute exacerbation of chronic cholecystitis</td>
			<td>Acute gangrenous cholecystitis</td>
			<td>Acute cholecystitis</td>
		</tr>
	</tbody>
</table>
Table 1: Outcomes of the surgery.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td rowspan="2">Demographics</td>
			<td>Patients underwent&#160;</td>
		</tr>
		<tr>
			<td>ICG-guided LC (n = 70)</td>
		</tr>
		<tr>
			<td>Average age (years)</td>
			<td>55.9 &#177; 14.1</td>
		</tr>
		<tr>
			<td>Sex</td>
			<td></td>
		</tr>
		<tr>
			<td>Male</td>
			<td>32</td>
		</tr>
		<tr>
			<td>Female</td>
			<td>38</td>
		</tr>
		<tr>
			<td>Average BMI (kg/m2 )</td>
			<td>25.2 &#177; 4</td>
		</tr>
		<tr>
			<td>History of upper&#160;abdominal surgery</td>
			<td>5</td>
		</tr>
		<tr>
			<td>Comorbidities</td>
			<td>28</td>
		</tr>
		<tr>
			<td>Hypertension</td>
			<td>18</td>
		</tr>
		<tr>
			<td>Diabetes</td>
			<td>13</td>
		</tr>
		<tr>
			<td>Cardiopathy</td>
			<td>13</td>
		</tr>
		<tr>
			<td>Hepatitis</td>
			<td>3</td>
		</tr>
	</tbody>
</table>
Table 2: Demographic data of the patients.

This protocol outlines the steps for fluorescence-guided laparoscopic cholecystectomy and elucidates the role of fluorescence navigation in diverse surgical scenarios.

The Role of Indocyanine Green Fluorescence in Complex Laparoscopic Cholecystectomy Navigation

Laparoscopic cholecystectomy (LC) is the gold-standard treatment for cholelithiasis and cholecystitis. In difficult cases with severe inflammation and ...

the-role-indocyanine-green-fluorescence-complex-laparoscopic

Nanyang Technological University

Research

JoVE Journal

Medicine

188 Views.  The Fifth Affiliated Hospital of Sun Yat-sen University. This protocol outlines the steps for fluorescence-guided laparoscopic cholecystectomy and elucidates the role of fluorescence navigation in diverse surgical scenarios.

Video: The Role of Indocyanine Green Fluorescence in Complex Laparoscopic Cholecystectomy Navigation

Development of an Audio-based Virtual Gaming Environment to Assist with Navigation Skills in the Blind

Audio-based Environment Simulator (AbES) is virtual environment software designed to improve real world navigation skills in the blind. Using only audio based cues and set within the context of a video game metaphor, users gather relevant spatial information regarding a building's layout. This allows the user to develop an accurate spatial cognitive map of a large-scale three-dimensional space that can be manipulated for the purposes of a real indoor navigation task. After game play, participants are then assessed on their ability to navigate within the target physical building represented in the game. Preliminary results suggest that early blind users were able to acquire relevant information regarding the spatial layout of a previously unfamiliar building as indexed by their performance on a series of navigation tasks. These tasks included path finding through the virtual and physical building, as well as a series of drop off tasks. We find that the immersive and highly interactive nature of the AbES software appears to greatly engage the blind user to actively explore the virtual environment. Applications of this approach may extend to larger populations of visually impaired individuals.

Audio-based Environment Simulator (AbES) is virtual environment software designed to improve real world navigation skills in the blind.

Audio-based Environment Simulator (AbES) is virtual environment software designed to improve real world navigation skills in the blind. Using only audio ...

Detecting Abnormalities in Choroidal Vasculature in a Mouse Model of Age-related Macular Degeneration by Time-course Indocyanine Green Angiography

Indocyanine Green&#160;Angiography (or ICGA) is a technique performed by ophthalmologists to diagnose abnormalities of the choroidal and retinal vasculature of various eye diseases such as age-related macular degeneration (AMD). ICGA is especially useful to image the posterior choroidal vasculature of the eye due to its capability of penetrating through the pigmented layer with its infrared spectrum. ICGA time course can be divided into early, middle, and late phases. The three phases provide valuable information on the pathology of eye problems. Although time-course ICGA by intravenous (IV) injection is widely used in the clinic for the diagnosis and management of choroid problems, ICGA by intraperitoneal injection (IP) is commonly used in animal research. Here we demonstrated the technique to obtain high-resolution ICGA time-course images in mice by tail-vein injection and confocal scanning laser ophthalmoscopy. We used this technique to image the choroidal lesions in a mouse model of age-related macular degeneration. Although it is much easier to introduce ICG to the mouse vasculature by IP, our data indicate that it is difficult to obtain reproducible ICGA time course images by IP-ICGA. In contrast, ICGA via tail vein injection provides high quality ICGA time-course images comparable to human studies. In addition, we showed that ICGA performed on albino mice gives clearer pictures of choroidal vessels than that performed on pigmented mice. We suggest that time-course IV-ICGA should become a standard practice in AMD research based on animal models.

Indocyanine Green Angiography (or ICGA) performed by tail vein injection provides high quality ICGA time course images to characterize abnormalities in mouse choroid.

Indocyanine Green&#160;Angiography (or ICGA) is a technique performed by ophthalmologists to diagnose abnormalities of the choroidal and retinal ...

Multicolor 3D Printing of Complex Intracranial Tumors in Neurosurgery

Three-dimensional (3D) printing technologies offer the possibility of visualizing patient-specific pathologies in a physical model of correct dimensions. The model can be used for planning and simulating critical steps of a surgical approach. Therefore, it is important that anatomical structures such as blood vessels inside a tumor can be printed to be colored not only on their surface, but throughout their whole volume. During simulation this allows for the removal of certain parts (e.g., with a high-speed drill) and revealing internally located structures of a different color. Thus, diagnostic information from various imaging modalities (e.g., CT, MRI) can be combined in a single compact and tangible object.
However, preparation and printing of such a fully colored anatomical model remains a difficult task. Therefore, a step-by-step guide is provided, demonstrating the fusion of different cross-sectional imaging data sets, segmentation of anatomical structures, and creation of a virtual model. In a second step the virtual model is printed with volumetrically colored anatomical structures using a plaster-based color 3D binder jetting technique. This method allows highly accurate reproduction of patient-specific anatomy as shown in a series of 3D-printed petrous apex chondrosarcomas. Furthermore, the models created can be cut and drilled, revealing internal structures that allow for simulation of surgical procedures.

The protocol describes the fabrication of fully colored three-dimensional prints of patient-specific, anatomical skull models to be used for surgical simulation. The crucial steps of combining different imaging modalities, image segmentation, three-dimensional model extraction, and production of the prints are explained.

Three-dimensional (3D) printing technologies offer the possibility of visualizing patient-specific pathologies in a physical model of correct dimensions. ...

Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating Acute Necrotizing Pancreatitis

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing pancreatitis, if it does not resolve or is accompanied with infected necrosis in the retroperitoneum. As there are rarely any visually clear separating surface in white light image between necrotic debris and adjacent inflammatory normal tissues due to extensive retroperitoneal adhesions, VARD is accompanied with the risk of vascular injury, external pancreatico-cutaneous or enterocutaneous fistulae. In view of the above disadvantages, we apply real-time intraoperative near-infrared fluorescence imaging with indocyanine green (ICG) during VARD, which enables visualization of the well-perfused adjacent normal tissues. This modified technique (ICG-guided VARD) can provide a clear separating surface during debridement and reduce the risk of vascular or enteric injury. ICG-guided VARD may facilitate surgeons to perform safer debridement in treating severe acute necrotizing pancreatitis.

This protocol presents Indocyanine Green-guided video-assisted retroperitoneal debridement (ICG-guided VARD) for treating severe acute necrotizing pancreatitis.

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing ...

Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. Surgery is the cornerstone treatment for patients with BC. While total BC excision and Roux-Y hepaticojejunostomy is the treatment method of the choice in patients with extrahepatic BC (i.e., Todani I-IV), patients with intrahepatic BC (i.e., Todani V) benefit the most from a surgical liver resection. In recent years, minimally invasive liver surgery (MILS) including robotic MILS has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. Robotic major MILS is still considered technically demanding and a detailed description of the technical approach during robotic major MILS has only been limitedly discussed in the literature. The current article describes the main steps for a robotic left hepatectomy in a patient with a large BC Todani Type V. The patient is in French position with 5 trocars placed (4 robotic, 1 laparoscopic assistant). After mobilizing the left hemiliver, the left and right hepatic artery are dissected carefully followed by a cholecystectomy. Intraoperative ultrasound is performed to confirm localization and margins of the BC. The Left hepatic artery and left portal vein are isolated, clipped, and divided. Indocyanine green (ICG) fluorescence imaging is used regularly during the entire procedure to visualize and confirm biliary tract anatomy and the BC. Parenchymal transection is performed with robotic cautery hook for the superficial part and robotic cautery spatula, bipolar cautery, and vessel sealer for the deeper parenchyma. The postoperative course was uncomplicated. A robotic left hepatectomy is technically demanding, yet a feasible and safe procedure. ICG-fluorescence imaging aids in delineating the BC and bile duct anatomy. Further, comparative studies are needed to confirm clinical benefits of robotic MILS for benign and malignant indications.

Robotic liver surgery has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. However, robotic left hepatectomy is still technically demanding. We describe our surgical technique of a robotic left hepatectomy using indocyanine green fluorescence imaging for a large biliary cyst.

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. ...

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic resection and reconstruction techniques, it is difficult to perform LPD for patients with locally advanced pancreatic head cancer after neoadjuvant therapy. Our team initiates LPD using the in-situ No-Touch isolation technique. The innovation and optimization of this modified No-Touch isolation technique emphasize exploring the distal section of superior mesenteric vein&#160;(SMV) and the left side of the superior mesenteric artery (SMA) prior to evaluating the resectability by subcolonic mesenteric approach, which is an ideal exploring approach. After that, we use the median-anterior, and left-posterior of SMA approaches to cut off the blood flow of the pancreatic head to make the tumor isolated intact, then move and dissect the tumor. It is a process fitting the surgical principle of tumor-free. This article aims to demonstrate the feasibility and safety of performing LPD using the in-situ No-Touch isolation technique, which might elevate the R0 resection rate. It is an oncological ideal operation process.

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

No-Touch isolation procedures might prevent the dissemination of cancer cells from the primary tumor. However, these techniques are not widely accepted in laparoscopic pancreatoduodenectomy (LPD) by now. We herein present in-situ No-Touch isolation LPD with partial resection and reconstruction of the superior mesenteric vein (SMV) for pancreatic cancer after neoadjuvant therapy.

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic ...

Dynamic Navigation in Endodontics: Guided Access Cavity Preparation by Means of a Miniaturized Navigation System

In the case of teeth with pulp canal calcification (PCC) and apical pathology or pulpitis, root canal treatment can be very challenging. PCC are common sequelae of dental trauma but can also occur with stimuli such as caries, bruxism, or after placing a restoration. In order to access the root canal as minimally invasive as possible in case of a necessary root canal treatment, dynamic navigation has recently been introduced in endodontics in addition to static navigation. The use of a dynamic navigation system (DNS) requires pre-operative cone-beam computed tomography (CBCT) imaging and a digital surface scan. If necessary, reference markers must be placed on the teeth before the CBCT scan; with some systems, these can also be planned and created digitally afterward. By means of a stereo camera connected to the planning software, the drill can now be coordinated with the help of reference markers and virtual planning. As a result, the position of the drill can be displayed on the monitor in real-time during preparation in different planes. In addition, the spatial displacement, the angular deviation, and the depth position are also displayed separately. The few commercially available DNS mostly consist of relatively large camera-marker-systems. Here, the DNS contains miniaturized components: a low-weight camera (97 g) mounted on the micromotor of the electric handpiece utilizing a manufacturer-specific connecting mechanism and a small marker (10 mm x 15 mm), which can be easily attached to an individually manufactured intraoral tray. For research purposes, a post-operative CBCT scan can be matched with the pre-operative one, and the volume of tooth structure removed can be calculated by the software. This work aims to present the technique of guided access cavity preparation by means of a miniaturized navigation system from imaging to clinical implementation.

Dynamic navigation systems (DNS) provide real-time visualization and guidance to the operator during endodontic access cavities preparation. The planning of the procedure requires three-dimensional imaging utilizing cone beam computed tomography and surface scans. After the export of the planning data to the DNS, access cavities can be prepared with minimal invasion.

In the case of teeth with pulp canal calcification (PCC) and apical pathology or pulpitis, root canal treatment can be very challenging. PCC are common ...

Laparoscopic Non-Mesh Cerclage Pectopexy for Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore apical support for treating POP. Sacrocolpopexy and pectopexy are indicated for apical prolapse. Using a synthetic mesh in these techniques increases success by enhancing apical support. However, the implantation of synthetic mesh is associated with mesh-related complications. In addition, the exorbitant cost of synthetic mesh and lack of universal access limit the popularity of these procedures. The current study develops a unique technique known as laparoscopic non-mesh cerclage pectopexy (LNMCP), in which permanent cervical cerclage sutures are embedded in the round ligament until the iliopectineal ligament. The iliopectineal ligament was sutured, resulting in a firm cervical suspension. The procedure was successfully performed in 16 cases in the hospital. The surgical duration was 67.8 min &plusmn; 15.5 min, and the blood loss was 73.1 mL &plusmn; 51.1 mL. No procedural complications were seen. LNMCP is associated with an objective success rate of 100% and a subjective success rate of 93.8%. LNMCP for patients with apical prolapse obviates the need for a mesh, thereby avoiding complications associated with mesh erosion and reducing medical costs. In addition, it is easy to perform even in resource-poor areas without access to synthetic mesh.

The present pilot study describes the development of laparoscopic non-mesh cerclage pectopexy to treat pelvic organ prolapse. The procedure can be used to prevent any complications associated with the use of mesh.

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore ...

Application of a New Mesh Fixation Method in Laparoscopic Incisional Hernia Repair

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing incisional hernias. The laparoscopic IPOM involves implanting the mesh into the abdominal cavity through laparoscopy to repair an abdominal wall hernia. In the IPOM surgery, after the closure of the hernia ring, an anti-adhesion mesh is placed laparoscopically. The correct placement of this mesh is critical to the success of the method, and surgical skills are required to achieve perfect placement. If the mesh placement is not mastered properly, the operation and anesthesia time will be prolonged. In addition, improper placement of the mesh can lead to serious consequences, such as intestinal obstruction and mesh infection. A "contraposition and alignment" mesh fixation method is described in this study, which involves pre-marking the fixation position of the mesh to reduce the difficulty of mesh placement. A properly placed mesh is completely flat on the peritoneum, the edges are not curled or wrapped, and the mesh is adhered firmly such that there is no displacement after removing the pneumoperitoneum pressure. The "contraposition and alignment" mesh fixation technique offers the advantages of reliable placement of the mesh and fewer complications than other techniques, and it is easy to learn and master. It also allows for positioning the nail gun in advance based on the anatomy of the incisional hernia. This enables the use of the minimum number of nails possible while still ensuring good fixation, which can reduce the occurrence of complications and reduce the cost of surgery. Thus, the mesh fixation method described here is highly suitable for clinical applications based on the aforementioned advantages.

Presented here is a method for improving the mesh placement in laparoscopic incisional hernia repair, which can shorten the time required for mesh fixation and reduce the occurrence of postoperative chronic pain.

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing ...

Laparoscopic Common Bile Duct Exploration in Patients with a Previous History of Biliary Tract Surgery

For recurrent choledocholithiasis, abdominal adhesions in previous surgeries lead to changes in anatomical structures, and a secondary injury occurs easily when performing another operation for laparoscopic common bile duct exploration (LCBDE), which was once considered a relative contraindication. In view of the limitations of the current surgical technique, this study summarized the surgical approaches and crucial anatomical landmarks for reoperation for LCBDE. Four general surgical approaches were proposed to expose the common bile duct, including the ligamentum teres hepatis approach, the anterior hepatic duodenal ligament approach, the right hepatic duodenal ligament approach, and the hybrid approach. Additionally, this study highlighted seven crucial anatomical landmarks: the parietal peritoneum, the gastrointestinal serosa, the ligamentum teres hepatis, the inferior margin of the liver, the gastric antrum, the duodenum, and the hepatic flexure of the colon, which were helpful to safely separate abdominal adhesions and expose the common bile duct. Moreover, to shorten the time of choledocholithotomy, a sequential method was innovatively applied for the removal of the stones in common bile duct. Mastering the above surgical approaches, including identifying crucial anatomical landmarks and adopting the sequential method will improve the safety of reoperation for LCBDE, shorten the operation time, promote the fast recovery of patients, reduce postoperative complications, and contribute to the popularization and application of this technique.

Programmed surgery based on surgical methods and anatomical markers helps shorten the operation time, reduce complications, and improve the safety of the surgery. This study investigated and summarized the surgical methods and anatomic markers of laparoscopic common bile duct exploration in patients with a history of biliary tract surgery.

For recurrent choledocholithiasis, abdominal adhesions in previous surgeries lead to changes in anatomical structures, and a secondary injury occurs ...