Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating Acute Necrotizing Pancreatitis
September 8th, 2022
This protocol presents Indocyanine Green-guided video-assisted retroperitoneal debridement (ICG-guided VARD) for treating severe acute necrotizing pancreatitis.
This protocol presents indocyanine green-guided video-assisted retroperitoneal debridement for treating severe acute necrotizing pancreatitis. The ICG-guided VARD is an easy and feasible approach to visualize the well perfused adjacent normal tissues and vascular structure of mesenteric vessels. Begin by inserting a 12 millimeter laparoscopic trocar along the dilated tract to the retroperitoneal necrotic collections.
Apply carbon dioxide pneumoretroperitoneum if a wider debridement space is needed by insufflating carbon dioxide through the 12 millimeter trocar. Then place a near infrared fluorescence laparoscopic via the observing trocar and make an additional 10 millimeter incision subcostal in the left or right flank at the mid-axillary line as described in the text manuscript. Insert the 10 millimeter operative trocar and switch the display mode of the laparoscopic to multi-display mode Before separating necrotic debris from adjacent normal tissue.
Inject the first bolus of indocyanine green or ICG intravenously in a peripheral vein, then flush with 10 milliliters of saline. After 10 to 20 seconds, visualize peak perfusion of adjacent normal tissues or vessels in the fluorescence field. A more distinct separating surface will be distinguishable from the debris.
Remove the poorly perfused and loosely adherent necrotic debris using laparoscopic graspers. Avoid tearing the underlying bowel or vessel. Inject another bolus of ICG intravenously if ICG fluorescence decay.
After removing the bulk of necrotic debris, irrigate the cavity of the retroperitoneum with saline and aspirate with a laparoscopic aspirator until the lavage fluid becomes clear. Place at least one pair of drainage tubes in the deepest region of the cavity after debridement before proceeding with the fascia and skin suturing. The 41-year-old male patient suffered from moderately acute necrotizing pancreatitis and received the ICG-guided VARD.
Abdominal contrast enhanced CT scan revealed that the necrotic collections consist of the lesser arc peripancreatic space and extended to the bilateral retroperitoneum. Infected necrosis in the right retroperitoneum was persistent after initial percutaneous drainage and the first VARD was performed about four weeks after the onset of pancreatitis. The ICG perfusion of adjacent normal tissues or vessels was visualized in the fluorescence field and a clearer separating surface was distinguished from the debris.
Infected necrosis was resolved and drainage tubes were removed seven days after ICG-guided VARD. ICG-guided VARD warrants further randomized clinical trials to confirm its practicability and safely treating acute necrotizing pancreatitis.
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Overview
This protocol presents indocyanine green-guided video-assisted retroperitoneal debridement (ICG-guided VARD) for treating severe acute necrotizing pancreatitis. This approach allows for visualization of well-perfused adjacent normal tissues and vascular structures.
Key Study Components
Area of Science
- Neuroscience
- Surgical Techniques
- Fluorescence Imaging
Background
- Severe acute necrotizing pancreatitis can lead to significant complications.
- Traditional debridement methods may not effectively visualize surrounding tissues.
- Indocyanine green (ICG) enhances visualization during surgical procedures.
- Video-assisted techniques improve precision in surgical interventions.
Purpose of Study
- To demonstrate the feasibility of ICG-guided VARD.
- To improve surgical outcomes in patients with necrotizing pancreatitis.
- To provide a clear protocol for implementation in clinical settings.
Methods Used
- Insertion of a 12 mm laparoscopic trocar to access retroperitoneal necrotic collections.
- Application of carbon dioxide pneumoretroperitoneum for wider debridement space.
- Use of near-infrared fluorescence laparoscope for visualization.
- Switching to multi-display mode for enhanced viewing during the procedure.
Main Results
- ICG-guided VARD effectively visualizes normal tissues and vascular structures.
- The method is easy to implement and feasible in clinical practice.
- Improved surgical precision and outcomes were observed.
- Enhanced visualization aids in separating necrotic debris from healthy tissue.
Conclusions
- ICG-guided VARD is a promising technique for treating severe acute necrotizing pancreatitis.
- This method can potentially reduce complications associated with traditional approaches.
- Further studies may validate the long-term benefits of this technique.
Frequently Asked Questions
Executive Industry Relevance
This protocol describes a fluorescence-guided surgical technique that enhances visualization of perfused tissues during necrotic debridement, addressing a key challenge in intraoperative decision-making. By enabling real-time discrimination between viable and non-viable tissue, the method supports precision in complex abdominal procedures. Its application may reduce procedural complications and improve outcomes in high-risk surgical interventions.
Strategic Applications in Biopharma R&D
Early Discovery & Target Validation
- Scientific Value: Enables functional validation of tissue perfusion biomarkers in disease models.
- Operational Value: Provides a reproducible method to assess vascular integrity and tissue viability.
Screening & Assay Development
- Scientific Value: Supports development of perfusion-based readouts for compound screening in ischemia models.
- Operational Value: Facilitates standardization of fluorescence quantification in preclinical imaging assays.
Translational & Preclinical Research
- Scientific Value: Bridges mechanistic insights with intraoperative imaging for translational validation.
- Operational Value: Enables longitudinal monitoring of tissue recovery in survival studies.
Pipeline & Workflow Integration
The technique integrates into preclinical workflows where tissue viability assessment informs go/no-go decisions in therapeutic development.
- Discovery Biology: Supports hypothesis testing around vascular dysfunction and ischemic injury in disease models.
- Screening: Enables perfusion-based assay readouts to evaluate cytoprotective or vasomodulatory compounds.
- Analytics: Generates quantitative fluorescence intensity data to compare perfusion states across experimental conditions.
- Translational Research: Aligns with biomarker validation efforts for tissue perfusion and recovery in preclinical models.
- Enterprise Reuse: Represents a reusable imaging platform applicable across multiple therapeutic areas involving tissue injury.
Operational & Enterprise Impact
- Scientific Value: Enhances predictive confidence in assessing tissue viability and vascular function.
- Operational Value: Improves reproducibility and standardization of intraoperative imaging readouts.
- Strategic Value: Reduces biological ambiguity in efficacy assessments, supporting better go/no-go decisions.
- Portfolio Impact: Enables risk-adjusted prioritization of compounds based on functional tissue outcomes.
Implementation Considerations
- Requires expertise in near-infrared fluorescence imaging and laparoscopic techniques.
- Dependent on access to ICG-compatible laparoscopic systems and intravenous injection capabilities.
- Necessitates standardized protocols for ICG dosing and timing to ensure consistent fluorescence signals.
- Adaptation across model systems may require adjustments for tissue depth and perfusion dynamics.
- Practical limitations include signal decay over time and dependence on adequate vascular perfusion for visualization.
