Description

Mastering Ureter Localization with Indocyanine Green: A Step-by-Step Guide In modern surgical practices, the localization of the ureters is a critical step to prevent inadvertent injury during abdominal or pelvic surgeries. Among the various techniques available, the use of Indocyanine Green (ICG) fluorescence imaging has emerged as a groundbreaking method for precise and real-time visualization of ureters. This step-by-step guide explores the principles, preparation, and execution of ureter localization using ICG, providing surgeons with a comprehensive approach to mastering this technique. Understanding Indocyanine Green Fluorescence Indocyanine Green (ICG) is a water-soluble, near-infrared fluorescent dye approved by the FDA for various clinical applications. When injected into the bloodstream, it binds to plasma proteins and emits fluorescence when exposed to near-infrared light. ICG's ability to highlight anatomical structures with minimal toxicity makes it ideal for ureter localization. Applications of ICG in Ureter Localization The use of ICG in ureter localization is especially beneficial in: 1. Minimally Invasive Surgeries: Such as laparoscopic or robotic procedures where direct visualization of the ureters is challenging. 2. Complex Surgical Cases: Involving distorted anatomy due to inflammation, malignancies, or previous surgeries. 3. Gynecological and Urological Surgeries: Including hysterectomies, endometriosis surgeries, and ureteral reconstructions. Step-by-Step Guide to Ureter Localization with ICG Step 1: Preoperative Preparation 1. Patient Assessment: Evaluate the patient's medical history for allergies to ICG or iodine, as cross-reactivity may occur. 2. Informed Consent: Explain the procedure and potential risks to the patient. 3. Equipment Check: Ensure the availability of fluorescence imaging systems compatible with ICG. Step 2: ICG Administration 1. Dosage Preparation: Prepare the ICG solution, typically at a concentration of 2.5 mg/mL. 2. Injection Route: Administer the ICG intravenously for vascular mapping or intravesically through a catheter for direct ureter visualization. 3. Timing: Allow sufficient time for the dye to distribute, usually 5-10 minutes post-injection. Step 3: Intraoperative Visualization 1. Activate the Imaging System: Utilize a near-infrared fluorescence camera integrated into the laparoscopic or robotic setup. 2. Identify the Ureters: Look for the characteristic bright fluorescence indicating the ureters. 3. Adjust Technique: Modify camera angles and lighting to enhance contrast and clarity. Step 4: Verification and Execution 1. Confirm Ureteral Location: Double-check the fluorescence signal to ensure accurate identification. 2. Proceed with Surgery: Maintain a safe distance from the ureters during dissection to prevent injury. 3. Document Findings: Capture intraoperative images or videos for reference and training purposes. Tips for Success • Optimize Lighting: Minimize ambient light in the operating room to improve fluorescence visibility. • Practice with Models: Gain proficiency with ICG imaging using simulation models or cadaveric studies before clinical application. • Stay Updated: Keep abreast of advances in fluorescence imaging technologies and their applications in surgery. Advantages and Limitations Advantages • Real-Time Visualization: Enhances safety and precision during surgeries. • Non-Invasive Nature: Minimal risk associated with ICG use. • Adaptability: Applicable across a variety of surgical specialties. Limitations • Cost and Availability: High initial setup costs for imaging systems. • Operator Dependency: Requires training and expertise for optimal use. • False Positives: Potential fluorescence from nearby structures or tissues. Conclusion The integration of Indocyanine Green fluorescence imaging into surgical practice represents a paradigm shift in ureter localization. By following this step-by-step guide, surgeons can effectively harness the benefits of ICG, minimizing complications and enhancing patient outcomes. Mastery of this technique not only improves surgical precision but also sets a new standard for patient safety in minimally invasive and complex surgeries.