Update Course 2021: ICG IN PED SURG

Welcome back everyone. Uh we're we're making the final turn on a great day of uh teaching and conferences. Uh it is my pleasure to introduce Dr. Chiro Esposito, uh chief of surgery at Naples uh Italy to discuss a topic that I love, ICG fluorescence in pediatric surgery. Chiro, thank you for being with us. Thank you very much, Mac. Thank you very much Todd is a pleasure to be with you and to share my experience in ICG fluorescence technology. I am some slides with videos with three cases that we can discuss. First of all, I have nothing to disclose and only a short introduction as you know in particular in pediatric MIS surgery is important to detect anatomic structure above all to reduce the incidence of complication for this reason the imaging technology has to help us as pediatric surgeon to do this. In the last three, four years we use in our operative room the near infrared in Green fluorescence imaging technology that is very useful in different indication. And is ICG insoluble molecule that is rapidly bound to albumin and is near instantaneously visualized with target. And it is removed from circulation by the liver and bile juice for this reason, one of the main indication is the surgery of gallbladder. Uh you to use this technology, you can adopt this technology use laparoscopy and you need an optic, you need for sure a camera, avile of ICG, but you can use also in robotic surgery because above all the last generation of Da Vinci system is a system called Firefly that can adopt ICG. I have three cases that we can discuss together. There are three three classic indication that I adopt in my clinical experience. For the first case is is a 12 years old boy a little bit fatty of 70 kilos with Gallstone disease and at the ultrasonography has several stones in the gallbladder. He he was and he had several episode of upper right quadrant pain and we have to decide what to do. which is the diagnostic work up before surgery or during surgery and above all which management is indicated. the first possibility can be ultrasonography and then medical therapy as you know sometime pediatric hepatology give for these children or acid therapy for some weeks. The second option is to use pre-operative US and then to perform the old fashion laparotomy to remove the gallbladder. Then another alternative is to perform pre-operatively colangio MRI and then to perform laparoscopic cholecystectomy or the classic pre-operative US and then start laparoscopy or pre-operative US and then laparoscopy but using ICG technology. I don't know if you can discuss a little bit and then I will show some slides as which is my aptitude in this case. Well, I suspect at this point people know that the right answer from you is E. Uh but if anybody wants to weigh in on another comment about other therapy, please do so. Yes, yes, I I agree completely with you. If you haven't uh ICG system in your hospital, some colleagues prefer to perform a pre-operative colangio MRI to have a clear anatomy of the biliary tree to avoid complication. If you haven't you have to perform US and standard laparoscopy. In the last three years we use ICG technology for this reason as uh you told us we prefer E, the pre-operative US and then laparoscopy using ICG technology. Why? Because if you analyze international literature, above all in adults, there are a lot of complication in laparoscopic cholecystectomy and this is particularly true in pediatric patients because as you know compared to the adults as you can see in these slides in the adults perform about 100 to 300 cholecystectomy per year in adult center compared to a pediatric center in which we perform 10 to 30 cholecystectomy per year. For this reason the learning curve is a little bit longer. And above all if you find this case as you can see uh in this slide in this uh video, there is uh the uh a complex case in which the anatomy is not clear because you don't know where is exactly the cystic duct, the main biliary area, you can have the complication. Thanks to ICG, you can have a real biliary mapping during the procedure. And uh the the ICG is in vial of 25 mg 4 ml. You have to dilute the vial with 10 ml of sterile water and then you have to inject 6 ml of ICG intravenously the day before surgery, above all uh 12 to 15 hour pre-operatively. In this way you have a clear view. As you can see in this video, this is the ICG technology. You can see very well the biliary anatomy. is absolutely amazing as you can see the main biliary tree, the gallbladder and then the cystic duct and you can perform a safe dissection and also in these other case, as you can see, there is a lot of additions and if you adopt ICG technology, you can see that there is an angulation of cystic duct with cystic fundus and thanks to ICG you can switch to a normal view to ICG view and to perform a very good isolation and above all you have always a very good view of main biliary tree. And this is a huge advantage during laparoscopic cholecystectomy above all for trainees. In this way you can low to zero the complication for this reason, I think is an amazing technology to adopt. Now you have a new uh ICG uh system because the old ICG system you have to switch with a pedal and you see the picture in black and white. Now which is the new Rubina system, you have the possibility to remain in color and the biliary tree is colored in green. is absolutely amazing. I think then thanks to this system, you can load the complication to zero because you have a very clear view of the anatomy as you can see in this picture is impossible to have a complication. The main drawback of this technique that you have to inject the product the day before surgery for this reason you have to plan in advance uh ICG technology for cholecystectomy and uh in my center, we use this uh technology routinely now for all the gallbladders. And this is the first case. I don't know if you if you want to to ask something or want to to to pass to to run indication. As you know as you. I think I think because of time limitations, we need to move ahead but uh okay, perfect. I'd like everybody to be thinking about when you give the ICG, the idea of giving it a day ahead of time, uh kind of kind of was new to me. So let's keep going though. Okay. That that's an important point Mac that I'm glad you brought up because I didn't know that either. Yes, as I told you, the the you have to plan the use in uh about the indication of ICG, because of the cholecystectomy is the only pathology in which you have to use to inject the product in advance because in other other indication as you can see for kidney, for lymphomas or for varicocele for indication, you have to use this intraoperatively, for this reason is easier. For cholecystectomy, you have to plan in advance. Why? Because if you use intraoperatively, you can see mainly the liver because is taken by the liver and you have the liver in green and it's difficult to identify the gallbladder. After 12, 15 hours, there is a secretion of ICG in the bile juice and you see electively the biliary tree. For this reason, this is the only indication to inject ICG in advance. The other indication as you can see in next slides, you have to use this technology intraoperatively for this reason for the surgeon is easier. So can I just clarify that for elective cases, you bring the patient in the day beforehand to get injected? Yeah, absolutely. We is hospitalized the day before surgery in the afternoon we perform the injection in the late afternoon if is operated early in the morning. So some for some of our liver cases we we have them come to clinic and we give the injection in clinic and then they can come back for surgery the following day. Yeah. To avoid the additional hospitalization day. Let's keep going. Okay. We can move to the second second indication of ICG. We move from GI to urinary tract. This is another classic example is a uh 27 months old girls of about 10 kilos with a duplex kidney with a non-functioning lower pole secondary to reflux. He has a terrial already treated using endoscopy in neonatal period and now she has urinary tract infection and urinary incontinence, probably for an ectopic terrial. As for the diagnostic workup and management indicated, there are several option as usual. There arephy and then clinical control plus antibiotic therapy considering that seal was already treated at birth. then the other optiontography and partialectomy using the old fashion laparotomy. The third option ishy becausehy needs essential to check the function of thety that we have to remove and partialectomy viatroscopy the option D istography with partialectomy using robotics also if there is a weight limit because as you know robotics you can use in general in patients higher than 10 15 kilos or you can usetography uh in pre-operative for for operative workup and then partialectomy and via laparoscopy using ICG and I will show you why. It looks like in the poll results that most of them are saying that the last choice using laparoscopy with ICG some over 70%. Yes, I think that this is the right answer because in laparotomy, I think is not no more indicated to to perform partialectomy. Using via retroperineoscopy, there is the problem because this child is has a reflux and it's difficult to remove the last part of the ureter and we are robotics at the moment the robots on the market is huge for this kind of children. For this reason we prefer to perform the procedure in laparoscopy and we use ICG why? Because you have three main advantage using this technology. First of all, you have the possibility to identify the ureter because when we perform a partialectomy, we put viacopy at beginning a catheter in the ureter and as you know when there is ax system, the two ureters are attached each other and using ICG injecting the catheter, you can identify the normal ureter that you have to save. Then you have to can clearly identify the vascularity, the vascularization of the kidney and above all of the kidney that you have to remove as you can see in the slide and the third advantage is that you have to inject the third time intraously ICG and you can identify after clipping the vessels of thety that you have to remove. There is the devascularization line. And you can see this is the the the the the videos. this is the the old system in which you see in black and white, but you can see very well the ureter, the normal ureter that is green. The ureter is attached and thanks to ICG technology, you can identify the ureter that is attached to the normal ureter. with the pedal, you can switch from ICG view to a normal view and you can start the dissection. As you can see, the normal ureter is very small and you can see green and the other is very big. If you switch to normal view is difficult to identify. The second and the second aspect, you have to inject intraously 2 ml of ICG solution and you can see the vascularization of the kidney. As you can see, this is the classic vascularization of a duplex kidney. You have to remove the lower pole. There is two huge vessels that vascularize the lower pole and thanks to the ICG technology, you can clearly identify them. And in this way it easy to isolate the two vessels and to save the main vessels because you have to to leave aty. And the the third part is that at the end of procedure after clipping the vessels, you can see the line of vascularization between thety that remain and the vascularizedty that you have to remove. In this way with the hook we mark this line and then using ceiling device, you can remove it. You can see clearly the upper pole that is very well vascularized and the lower pole that is devascularized. And as I told you also uh using uh the new Rubina system the uh you can remain in color. And as you can see it easy to operate, you can see the normal ureter in green on lower part of your screen and on the upper part there is the huge ureter of thety that you have to remove. Thanks to this technology as you can see, you can perform a safe surgery, avoid danger for the other ureter and this is the same also at level of the kidney as you on the kidney. You can see uh if you inject intravenously um the ICG you can see the vascularization. This is a lower an upper pole that you have to remove is another case and you can see in green the vascularization of the upper pole. To summarize the advantage to use ICG for partialectomy uh you have to inject this product three times. The first of all you have to performpy before surgery. You put a catheter in normal ureter and you have to inject ICG inside a catheter and you can identify the normal ureter and you can save it. Second injection intraously, intraoperatively. In one minutes you can see the vascularization of thety that you have to remove. Then you clip the vascularization of thety that you have to remove and you have to perform a third injection always of 2 ml intravenously and you can see the line of devascularization. In this way you can perform an easy surgery and a safe surgery. And that's all for partialectomy. Let's uh let's keep going. Uho, thank you. Okay. And then the the last case is varicocele. As you know varicocele is a big problem because there are several uh indication for treatment, several techniques that you can adopt. Sometimes in Europe, the technique that we can adopt is different from US. I will show you one classic case that we operate in in Europe. is a 13 years old boy with a great four varicocele according to Dublin and classification and he has an hypotrophic lateral testis and he has left testis pain and is a classic indication for surgery for us. There is nogram available because he's too young to do it and for this reason we have to decide which is the workup and the management of these children. The first option is to perform an echo color Doppler and clinical controls because there is an option because we havenogram for this reason you can control until 16 years then to performram and then to check the management. The second option is to perform ancocolor Doppler and then to perform an openinal approach. This is the pathology that in Europe sometimes adopt the adult surgery at the surgeons and the third option is to perform eco color Doppler technique and then sclerolization then the fourth option is to perform ecocolor Doppler andscopic in which yougate the spermatic bundle but you spare the testicular artery or ecocolor Doppler and then to perform procedure in which you clips and section spermatic bundle but using ICG. My option is the the the the E usingscopic with ICG and I will show you why. As you know that if you performmo, you have the the higher rate of success more than 97, 98%, but if you performmo, yougate also the lymphatic vessels. In the spermatic bundle, there are three four lymphatics and if yougate lymphatics, you can have a postoperative seal in about 20% of cases. We published study together with some uh some colleagues but after the introduction of in Green, you can have an intraoperative fluorescence lymphography. In this way you can spare the lymphatics that you have no seal. To perform this procedure, you have to inject the product intratesticular. You have to always to create a solution as I show you and then you have to inject 2 ml of solution inside the testis and you can see the uh uh lymphatics colored in green and is extremely easy to spare the lymphatics. This is the old system in which you have an black and white view, but as you can see is extremely easy and safe to spare the lymphatics. If you switch to colored view, you can see also the lymphatic that is colored in green, but you switch to um ICG view is better. And then after the uh section of the spermatic bundle, you can check there are the lymphatics and we use this technique for more than 150 patients and we have zero seal in post-operative period. And thanks to the new technology, this is the ICG Rubina system is the special camera that permits to remain in color as as you can see, uh the uh lymphatics are colored in green and you remain in color and you can perform dissection easily and you can spare lymphatics. In conclusion, some consideration you need to use this technology is absolutely amazing. Uh is uh you have you need the special equipment. Uh if you use laparoscopy, you need the camera and the optic or you need if you have an XI robots with Firefly system and for sure avile of ICG. The timing of injection change accordingly to the indication as for cholecystectomy is the only indication in which you have to inject in advance the day before for this reason you have to hospitalize the patient the day before surgery. For all other indication, kidney, varicocele, nodes or tumors, you have to inject intraoperatively. There is real advantage for surgeon, no adverse effect in our experience and you can use the vial for six hours. This is the main indication for memi partialectomy, varicocele are the best indication but also lymphomas, tumors or to check the vascularization of anastomosis is other indication. you have to develop this. And in conclusion, I think is a safe and useful and versatile technique to adopt in pediatric MIS to have a better visualization a surgical anatomy. is absolutely amazing, you have to use it above all for cholecystectomy because you can avoid complication and above all can help surgeon to reduce complication for example for cholecystectomy in which you have few cases per year and I think that this technology can be considered in selected cases as you can show you to increase safety of laparoscopic procedure. And that's all thank you. Thank you so, thank you so much. That was outstanding. Uh any one comment from any of the the faculty or panelist that uh I just have a quick question. I have a quick question. Can you overdose on that like you said you get three three injections for uh for the kidney surgery. Um is there is there a maximal dose you can give? Uh, there is no limits. As you know, uh this technology was used, I think more than five years ago from adult surgeons. There are great study performed from Jack Maresco atcad as for cholecystectomy and there is no limit for those that you can you can adopt. Uh, you have I think there is a lot of indication and probably we have to discover other indication. I know that Steve Rothenberg adopt this technology also for tumors. We adopt for to identify nodes for lymphomas or to for uh to check the vascularization of the anastomosis. As for the partialectomy, the first injection is inside the catheter for this reason is not intraously. And there the other two injection are intraously but there is no problem because he secreted by juice. So um this obviously Chiro, thank you so much for coming, Mac, thank you for moderating that. There's obviously going to be a million questions. I think we've seen today that ICG is definitely something to be paying attention to. This is something that every day we're finding more and more uses. We can probably go through all of us and figure out different cases that we've tried it on, thyroids, uh thoracic duct leaks, all these different things. So it's it's really we're getting more and more and next year we'll probably know more. Thank you for that incredible presentation Chiro and thank you for joining us from across the ocean.