Standardization of indocyanine green (ICG) fluorescence in emergency surgery for small bowel obstruction: a preliminary experience

Abstract

Aim: Indocyanine green (ICG) fluorescence is not routinely used in acute small bowel obstruction (SBO), and standardized methods for its use in assessing intestinal perfusion, particularly via laparoscopy, remain lacking. Therefore, we aimed to explore its role in acute SBO in elderly and frail patients undergoing operative management.

Methods: In this single-center, prospective, non-randomized study, we included a case series of patients who underwent emergency laparoscopic surgery for SBO from January 2024 to January 2025 at an Italian community hospital. Patients included were those with acute SBO confirmed by computed tomography scan, who provided signed informed consent, had no allergy to ICG, and were ≥ 18 years old. In borderline cases of intestinal ischemia, we standardized the application of ICG fluorescence to help determine the need for intestinal resection: ICG dosage, timing of injection, timing of fluorescence imaging capture and assessment of the intestinal segment. The postoperative course and the need for re-intervention were evaluated.

Results: ICG fluorescence was applied in 16 patients. Half of the cases were male, the median age was 72 years old, 63% presented an American Society of Anesthesiologists (ASA) Physical Status score of 3-4, and the median Charlson Comorbidity Index was 3. Conversion rate was 37%. Main causes of SBO were strangulated hernia, adhesive bands, adhesions and vascular ischemia. In 6 patients, ICG fluorescence showed a non-fluorescent or perivascular pattern, prompting an intestinal resection. Two patients needed re-intervention. Postoperative complications occurred in 43% of the patients.

Conclusion: SBO often affects elderly and frail patients. ICG fluorescence serves as a useful and feasible tool in emergency laparoscopic surgery. It facilitates the surgical assessment in borderline cases of intestinal ischemia, thereby preventing unnecessary bowel resections.

Keywords

Indocyanine green fluorescence / laparoscopic emergency surgery / small bowel obstruction / intestinal ischemia / intestinal resection / frail patients

References

[1] Boni L,David G,Fingerhut A. ICG-enhanced fluorescence-guided laparoscopic surgery. 2nd ed. Tuttlingen (DE): EndoPress; 2019. Available from: https://air.unimi.it/retrieve/dfa8b9a3-43cc-748b-e053-3a05fe0a3a96/ICG-Enhanced%20Fluorescence-Guided%20Laparoscopic%20Surgery%20%E2%80%93%202nd%20edition.pdf. [Last accessed on 12 Mar 2026]

[2] Kalayarasan R,Sai Krishna P.Indocyanine green fluorescence in gastrointestinal surgery: appraisal of current evidence.World J Gastrointest Surg2023;15:2693-708 PMCID:PMC10784830

[3] Perini D.Don’t forget emergency surgery! Lessons to learn from elective indocyanine green-guided gastrointestinal interventions.World J Gastrointest Surg2024;16:270-5 PMCID:PMC10921208

[4] Fransvea P,Puccioni C.Application of fluorescence-guided surgery in the acute care setting: a systematic literature review.Langenbecks Arch Surg2023;408:375

[5] Furusawa K,Matsukawa H,Yunoki K.Precise diagnosis of acute mesenteric ischemia using indocyanine green imaging prevents small bowel resection: a case report.Int J Surg Case Rep2022;97:107463 PMCID:PMC9403293

[6] Аlexander K,Alexander M.Use of ICG imaging to confirm bowel viability after upper mesenteric stenting in patient with acute mesenteric ischemia: case report.Int J Surg Case Rep2019;61:322-6 PMCID:PMC6718363

[7] Nakashima K,Okamoto A.Usefulness of blood flow evaluation with indocyanine green fluorescence imaging during laparoscopic surgery for strangulated bowel obstruction: a cohort study.Asian J Surg2022;45:867-73

[8] Bulkley GB,Hamilton SR,Klacsmann PG.Intraoperative determination of small intestinal viability following ischemic injury: a prospective, controlled trial of two adjuvant methods (Doppler and fluorescein) compared with standard clinical judgment.Ann Surg1981;193:628-37 PMCID:PMC1345136

[9] Coco D,Fiume I.Small bowel obstruction: a prognostic score index for surgery - a review.Prz Gastroenterol2022;17:177-82 PMCID:PMC9475473

[10] Ghimire P.Adhesive small bowel obstruction: a review.JNMA J Nepal Med Assoc2023;61:390-6 PMCID:PMC10089019

[11] Costa G,Podda M.The use of emergency laparoscopy for acute abdomen in the elderly: the FRAILESEL Italian Multicenter Prospective Cohort Study.Updat Surg2020;72:513-25

[12] Podda M,Di Saverio S.Adhesive small bowel obstruction and the six w’s: who, how, why, when, what, and where to diagnose and operate?.Scand J Surg2021;110:159-69

[13] Sermonesi G,Vallicelli C.Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma.World J Emerg Surg2023;18:57 PMCID:PMC10704840

[14] Karampinis I,Jakob J.Indocyanine green tissue angiography can reduce extended bowel resections in acute mesenteric ischemia.J Gastrointest Surg2018;22:2117-24

[15] Suh SW.Laparoscopy for small bowel obstruction caused by single adhesive band.JSLS2016;20:e2016.00048 PMCID:PMC5026458

[16] Vettoretto N, Carrara A, Corradi A, et al.; Italian Association of Hospital Surgeons (Associazione dei Chirurghi Ospedalieri Italiani-ACOI). Laparoscopic adhesiolysis: consensus conference guidelines.Colorectal Dis2012;14:e208-15

[17] Ten Broek RPG,Di Saverio S.Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group.World J Emerg Surg2018;13:24 PMCID:PMC6006983

[18] Shinall MC Jr, Arya S, Youk A, et al. Association of preoperative patient frailty and operative stress with postoperative mortality.JAMA Surg2020;155:e194620 PMCID:PMC6865246

[19] Agresta F,Campanile FC,Anania G.Emergency laparoscopic surgery in the elderly and frail patient. Cham (CH): Springer Nature; 2021.

[20] Jeppesen M,Gögenur I.Chronic pain, quality of life, and functional impairment after surgery due to small bowel obstruction.World J Surg2016;40:2091-7

[21] Ortenzi M,Sartori A.Low-pressure versus standard-pressure pneumoperitoneum in laparoscopic cholecystectomy: a systematic review and meta-analysis of randomized controlled trials.Surg Endosc2022;36:7092-113 PMCID:PMC9485078

[22] Rami Reddy SR, Cappell MS. A systematic review of the clinical presentation, diagnosis, and treatment of small bowel obstruction.Curr Gastroenterol Rep2017;19:28

[23] Tolstrup MB,Gögenur I.Morbidity and mortality rates after emergency abdominal surgery: an analysis of 4346 patients scheduled for emergency laparotomy or laparoscopy.Langenbecks Arch Surg2017;402:615-23

[24] Christofi A,Dimitroulis D.Near-infrared indocyanine green angiography in recognizing bowel ischemia in emergency surgery: game changer or overrated?.Innov Surg Sci2024;9:113-21 PMCID:PMC11415940

[25] Seeliger B,Mascagni P.Simultaneous computer-assisted assessment of mucosal and serosal perfusion in a model of segmental colonic ischemia.Surg Endosc2020;34:4818-27

[26] Ryu S,Goto K.Fluorescence angiography vs. direct palpation for bowel viability evaluation with strangulated bowel obstruction.Langenbecks Arch Surg2022;407:797-803

[27] Guerra F,Greco PA,Patriti A.The use of indocyanine green fluorescence to define bowel microcirculation during laparoscopic surgery for acute small bowel obstruction.Colorectal Dis2021;23:2189-94

[28] De Simone B, Abu-Zidan FM, Saeidi S, et al.; ICG Fluorescence Guided Emergency Surgery Survey Consortium. Knowledge, attitudes and practices of using indocyanine green (ICG) fluorescence in emergency surgery: an international web-based survey in the ARtificial Intelligence in Emergency and trauma Surgery (ARIES)-WSES project.Updates Surg2024;76:1969-81 PMCID:PMC11853863