Minimally invasive liver surgery now allows almost all liver resection operations to be performed safely. The advent of robotic surgery has allowed further development of these surgeries. In this field, any artifice that can further benefit the surgeon in performing these particular hepatic resections is certainly desired. Indocyanine green has shown to be extremely useful in verifying the anatomy of the liver and biliary tract, in the discovery of small tumor nodules located in the more peripheral areas of the liver and in the intraoperative definition of liver segmentation.
Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Surface MalignanciesMary Ondinee Manalo Igot
The prognosis of most peritoneal surface malignancies were previously dismal. However, with the incorporation of HIPEC to standard of care, we have been seeing doubling of survival for select malignancies. Appropriate patient selection is crucial.
Indocyanine green (ICG) in liver surgery.pptxGian Luca Grazi
The use of indocyanine green has now become common practice during liver and biliary tract surgery. This dye helps in defining the anatomy of the liver segments and is able to provide data on the course of the biliary tract. Furthermore, it can detect the presence of small superficial tumors, increasing the cure potential of liver resections in the treatment of liver tumors.
This reading reviews the main uses of indocyanine green in liver surgery, in particular for laparoscopic and robotic surgery, and opens a window on the future clinical developments of indocyanine green in the treatment of liver tumors.
Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Surface MalignanciesMary Ondinee Manalo Igot
The prognosis of most peritoneal surface malignancies were previously dismal. However, with the incorporation of HIPEC to standard of care, we have been seeing doubling of survival for select malignancies. Appropriate patient selection is crucial.
Indocyanine green (ICG) in liver surgery.pptxGian Luca Grazi
The use of indocyanine green has now become common practice during liver and biliary tract surgery. This dye helps in defining the anatomy of the liver segments and is able to provide data on the course of the biliary tract. Furthermore, it can detect the presence of small superficial tumors, increasing the cure potential of liver resections in the treatment of liver tumors.
This reading reviews the main uses of indocyanine green in liver surgery, in particular for laparoscopic and robotic surgery, and opens a window on the future clinical developments of indocyanine green in the treatment of liver tumors.
Hyperthermic Intraperitoneal Chemotherapy is more effective in killing the cancer cells which are spread in the tummy region. This technique needs a specialized, dedicated team, HIPEC machine and trained doctors and is done immediately after the cytoreductive surgery.
Practical considerations in soft tissue sarcoma 3Sameer Rastogi
It deals with contemporary issues with the management of soft tissue sarcomas. It deals with almost every aspect of soft tissue sarcoma including radiology, pathology, treatment, follow up etc.
Artery first approach For Pancreatic Head tumours by Dr Harsh Shah (www.gastr...Dr Harsh Shah
Artery first approach to Pancreatic head tumour. There are various approaches as described in this presentation. Pros & Cons of all approaches are discussed.
Chemotherapy for liver metastases from colorectal cancer now makes it possible to reduce their size. Sometimes these metastases can even disappear. This does not mean that the metastases are cured and surgical removal is always advisable. The main problem is how to identify these "vanishing" metastases during liver resection and how to perform truly effective interventions from an oncological point of view.
Hyperthermic Intraperitoneal Chemotherapy is more effective in killing the cancer cells which are spread in the tummy region. This technique needs a specialized, dedicated team, HIPEC machine and trained doctors and is done immediately after the cytoreductive surgery.
Practical considerations in soft tissue sarcoma 3Sameer Rastogi
It deals with contemporary issues with the management of soft tissue sarcomas. It deals with almost every aspect of soft tissue sarcoma including radiology, pathology, treatment, follow up etc.
Artery first approach For Pancreatic Head tumours by Dr Harsh Shah (www.gastr...Dr Harsh Shah
Artery first approach to Pancreatic head tumour. There are various approaches as described in this presentation. Pros & Cons of all approaches are discussed.
Chemotherapy for liver metastases from colorectal cancer now makes it possible to reduce their size. Sometimes these metastases can even disappear. This does not mean that the metastases are cured and surgical removal is always advisable. The main problem is how to identify these "vanishing" metastases during liver resection and how to perform truly effective interventions from an oncological point of view.
The indications and preparation for laparoscopic liver surgery remain the same as in open hepatic surgery. Visualization is excellent with the laparoscope, and the addition of laparoscopic ultrasound has been shown to help intraoperative plans in 66% of cases when compared to laparoscopic exploration alone.
An Unusual Presentation of Endoscopic Retrograde Cholangio Pancreatogram Ind...Apollo Hospitals
Perforation is a known complication of Endoscopic Retrograde Cholangio Pancreatogram (ERCP).
We are presenting a case of acute cholecystitis with obstructive jaundice, who developed gross pneumoperitoneum after ERCP, detected on X-ray abdomen. In this case ERCP was done for suspected choledocholithasis. Biliary stent was also done. Patient was managed conservatively and planned for laparoscopic cholecystectomy later.
During laparoscopy we found part of biliary stent visible in gallbladder area.
Traditionally, perforation after ERCP has been managed surgically. But this can be managed conservatively in selective patient.
In this case report there are two unusual findings- (i) asymptomatic presentation of post ERCP perforation (ii) Proximal part of biliary stent lying outside the biliary system in GB neck area.
Parenchyma-sparing surgery in the resective treatment of liver metastases, particularly for those originating from colon and rectal tumors, is an approach that has gained great appreciation in recent years. Parenchyma sparing must not be understood only as the sole execution of operations limited to the removal of metastases, but as a real operating strategy aimed at more conservative interventions, which preserve the vascular and iliar structure of the liver itself. For example, the resection of two contiguous segments, despite being an anatomical surgery, can and must still be considered as a liver parenchyma-sparing surgery compared to a major hepatectomy. This presentation retraces the history of liver resections performed for liver metastases and revisits the evolution of surgery that has led to parenchyma-sparing liver surgery being defined as the golden standard.
Liver resections after iatrogenic vasculobiliary lesions or for post traumati...Gian Luca Grazi
Liver trauma is still a condition burdened by significant mortality and high morbidity. Although today the treatment of patients who have suffered liver trauma is essentially conservative, there is still a certain number of patients who require liver resection surgery. The indication in these cases may be due either to the presence of a major lesion of the vascular or biliary pedicles, or to the onset of major phenomena of necrosis of the liver parenchyma (MHN). In this presentation the main aspects of the surgical treatment of these patients are taken into consideration and the indications for performing a hepatectomy are critically revisited.
Cholangiocarcinoma Risk stratification - Prognostic factors related to the pa...Gian Luca Grazi
The prognosis of patients with cholangiocarcinoma generally remains very low. However, patients who manage to have an indication to perform liver resection surgery can hope for a certain increase in survival. In this context, one of the most important problems is the definition of prognostic factors for survival after hepatectomy, in order to avoid useless if not harmful interventions. This presentation revisits the main prognosis systems published in the scientific literature regarding cholangiocarcinoma and performs a critical evaluation of them.
Pancreatic surgery has now established as the only potentially curative therapy for pancreatic adenocarcinoma. However, 3-year survival after radical oncological surgery remains limited to 30-40% and between 20 and 30% after 5 years. To date, there are no aids that have substantially improved these results. This presentation addresses the most debated topics on the subject. The first is related to the pre-operative management of patients. There are now definite scientific evidences that show how the placement of biliary drainages inevitably lead to an increase in post-operative infectious complications. For this reason, if possible, it is now preferable to perform pancreatic resections even in the presence of jaundice. The second argument concerns the role of neo-adjuvant therapy. There is growing data indicating an improvement in results in patients who have performed this therapy, even if the number of patients who do not then undergo surgery remains substantial. Finally, the presentation talks about the centralization of pancreatic surgery, with a marked improvement in the results for patients who are operated on in high-volume centres.
Liver failure after major hepatic resection.pptxGian Luca Grazi
Liver failure after hepatic resection has a multifactorial origin. However, the volume of the removed liver, technical problems during the procedure and the development of infections in the post-operative period certainly play a primary role.
The surgeon plays an important role in implementing all those surgical and radiological procedures to prevent the onset of this severe complication.
However, the treatment of liver failure that occurs after a hepatectomy requires multidisciplinary management, including intensive care physicians, neurologists, nephrologists, and others.
In order not to incur in the failure to recognize the complication and to avoid not implementing all the therapeutic measures necessary for the treatment of post-resection liver failure, it is essential that the hospital where the operation is performed is equipped with all professionalism and all the necessary technological tools.
These are the characteristics needed to define where liver surgery can be performed safely.
Hepatobiliary surgery - role in liver diseases.pptxGian Luca Grazi
Over the past 40 years, liver surgery has become an independent branch of general surgery and abdominal surgery. Liver resections are now well-coded procedures that require sophisticated planning. There are many diseases that can be treated with surgery in the context of liver diseases. This presentation reviews the indications for surgery in the field of primary liver tumors (mainly hepatocellular carcinoma), in the field of benign hepatic tumors, in the field of acute and chronic biliary diseases.
Performing vascular resections during a liver resection is a complex procedure, that is often carried out for advanced tumor diseases. Certainly, the removal of a tumor recurrence or a residual disease that has infiltrated one of the liver vessels (hepatic artery, portal vein, hepatic vein or inferior vena cava) can allow the patient to enjoy a further period of well-being, independently to the possibility of being able to perform adjuvant chemotherapy. However, in most cases, performing a vascular resection involves an increased risk of mortality and morbidity. Furthermore, the results in terms of long-term survival are often discouraging.
Minimally invasive liver surgery has recently acquired the surgical robot among the available weapons. In particular, the “Da Vinci” Robot currently represents the operative standard. Liver resections are now increasingly performed robotically. The increased experience has made these robotic procedures ever simpler and safer to perform. In this presentation, we review the basic steps for dealing with a robotic liver resection. The tools available to perform a robotic hepatectomy also occur. However, at the present time, the robotic surgical instruments completely studied and realized for their application on the liver are very few.
Treatment of metachronous liver metastases from colorectal cancer sees surgery as the primary therapy. However, in recent years, several factors have emerged that have led to considering liver resection as an increasingly personalized practice. Liver resections are now placed within the "precision surgery". Even if in the presence of different guidelines published in the scientific literature, very often the attitude of the various hepatobiliary surgery centers, and even of the individual surgeons, is not homogeneous and different (sometimes very different) are the attitudes that direct towards the 'one or the other surgery.
Conversion from laparoscopy to open technique during laparoscopic liver resections. Which are the causes and how it might be possible to avoid them. Presented at the Palermo meeting of the Italian register "I Go Mils" on liver resections carried out by a mini-invasive approach (both laparoscopic and robotic)
Minimally invasive pancreatic surgery has led to the identification of new technical challenges.
An important aspect is to verify the possibility of performing vascular resections during pancreatic resection procedures for cancer.
Difficulty scores for laparoscopic liver resectionsGian Luca Grazi
A critical analysis of the scores proposed to define the difficulty of performing laparoscopic liver resections. Four scores are too many. The information they offer differs in content.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
5. ICG guided robotic surgery
HCC
38%
Metastases
18%
Other Cancers
4%
CCA
12%
Benign
28%
Diagnosis
Left lateral
sectionectomy
12%
Minor resections
42%
1-2 Segments
34%
Left hepatectomy
5%
Right hepatectomy
7%
Type of Resection
6. ICG guided robotic surgery
One major drawback of minimally-invasive
surgery is the lack of haptic feedback, since
palpation with laparoscopic or robotic forceps is
limited.
The surgeon must rely on his/her own visual
impressions, making parenchymal dissections
particularly problematic
7. ICG guided robotic surgery
• Indocyanine green (ICG) was approved by the Food and Drug Administration (FDA) in
1957 and has been used in various medical fields.
• Since the 1980s, ICG has been used to test liver function prior to hepatobiliary surgery.
• In this indication (LiMON test), ICG is administered intravenously days before surgery
and the blood concentration and ICG plasma disappearance rates are measured
noninvasively.
• In healthy liver tissue, ICG is fully excreted after 72 h and no remnants should be
detectable.
• In 2009 it was noticed ICG accumulation in hepatocellular carcinoma (HCC) and hepatic
metastasis (HM) of colorectal cancer up to 14 days after ICG application for liver
function evaluation
Brief History of Indocyanine Green
8. ICG guided robotic surgery
In open surgery, additional near-infrared (NIR) cameras and/or monitors are
needed for ICG visualization, theater lights need to be switched off, and the
operating surgeon must remove their focus from the operation field while
performing crucial parts of the operation.
In laparoscopic surgery, the NIR camera is integrated into some systems.
The Firefly™camera (Intuitive, Sunnyvale, CA, USA) is integrated in the da
Vinci Surgical Systems (Intuitive, Sunnyvale, CA, USA) and can easily be used
to intraoperatively visualize ICG accumulation.
Usage in Surgery
9. ICG guided robotic surgery
Indocyanine Green Fluorescence Navigation in Liver Surgery
A Systematic Review on Dose and Timing of Administration
Wakabayashi T, Ann Surg 2022;275:1025–1034
10. ICG guided robotic surgery
•Time of administration
•Dose to be given
•Impaired liver function (fibrosis or cirrhosis)
•Elderly patients with slower metabolism
Open Questions in the usage of Indocyanine Green
11. ICG guided robotic surgery
The reported depth penetration is
limited to a maximum of ≈ 8 mm
12. ICG guided robotic surgery
1.Study of the anatomy, mainly biliary
2.Detection of bile leaks
3.Guiding mini-invasive liver resections
4.Intra operative tumor staging
15. ICG guided robotic surgery
1.Study of the anatomy, mainly biliary
2.Detection of bile leaks
3.Guiding mini-invasive liver resections
4.Intra operative tumor staging
16. ICG guided robotic surgery
On POD3, the bilirubin levels in the drainage fluid were
significantly lower in the IO-G than in the CO-G. Bars indicate
the median values and interquartile ranges.
Bilirubin levels in serum and drainage effluent on the third postoperative day (POD3).
Hanaki T, Anticancer Res 2022,42:4787-4793
17. ICG guided robotic surgery
1.Study of the anatomy, mainly biliary
2.Detection of bile leaks
3.Guiding mini-invasive liver resections
4.Intra operative tumor staging
18. ICG guided robotic surgery
Ishizawa T, Arch Surg 2012, 147: 393-394
Positive staining Negative staining
The portal branch of the segment to be resected is
punctured with a needle.
The ICG dye (0.025 mg in 10 mL of normal saline) is
injected without clamping the hepatic artery.
The liver surface of segment to be resected starts to
fluoresce following the injection of the ICG dye.
The intensity of the fluorescence on the surface of
segment to be resected is highest 10 minutes after
injection, which allows clear differentiation between
segment to be resected and adjacent.
The positive-staining technique with ICG dye does not
require hepatic artery clamping.
The root of the portal pedicle of the segment to be
resected had to be temporarily clamped and the ICG dye
(2.5 mg in 1 mL of normal saline) is intravenously
injected.
All hepatic segments, except segment to be resected,
are clearly fluorescent 1 minute after injection.
The hepatic segments with maintained portal and
arterial blood flow are illuminated with ICG demarcating
the area to be resected.
Positive and Negative Staining of Hepatic Segments by Use of Fluorescent
Imaging Techniques During Laparoscopic Hepatectomy
20. ICG guided robotic surgery
Indocyanine Green Fluorescence Navigation in Liver Surgery
A Systematic Review on Dose and Timing of Administration
Wakabayashi T, Ann Surg 2022;275:1025–1034
23. ICG guided robotic surgery
Chiow AKH, HPB 2021, 23: 475-482
Robotic ICG guided anatomical liver resection in a multicenter cohort: an
evolution from “positive staining” into “negative staining” method
24. ICG guided robotic surgery
• Robotic ICG guided hepatectomy technique for anatomical
liver resection is safe and feasible and has the potential
benefit for improving visualization of the demarcation line
especially in living donor liver graft harvest and cirrhotic
patients with minimal complications.
• The negative staining technique was easy to perform and
is recommended in major anatomical resections.
Chiow AKH, HPB 2021, 23: 475-482
26. ICG guided robotic surgery
1.Study of the anatomy, mainly biliary
2.Detection of bile leaks
3.Guiding mini-invasive liver resections
4.Intra operative tumor staging
29. ICG guided robotic surgery
ASSOCIATING INTRAOPERATIVE INDOCYANINE
GREEN FLUORESCENCE IMAGING AND
ULTRASOUND TO DETECT MICROSCOPIC CANCER
LESIONS DURING HEPATIC SURGERY
Scarinci A, Di Filippo S, Palmieri A, Police A, Marcelli ME,
Diodoro MG, Grazi GL
Abstract – Oral presentation
8 patients
Evaluated with CT/MR + IOUS
• 4 HCC
• 2 METS
• 2 CCA
Additional resection
6 patients
Planned resection
2 patients
11 more nodules
7
Tumoral
nodules
4
non tumoral nodules
2 regenerative nodule
1 fat containing cell
1 cirrhosis
30. ICG guided robotic surgery
Boogerd LSF, Surg Endosc 2017, 31: 952-961
Sensitivity of all imaging modalities employed.
Sensitivity and positive predictive value of computed tomography (CT), magnetic resonance imaging (MRI), visual
inspection, laparoscopic ultrasonography (LUS), near-infrared fluorescence imaging (NIRF), and combination of LUS and
NIRF.
Twenty-two patients planned
to undergo laparoscopic
staging (n = 4) or resection (n
= 19) of one or multiple
tumors confined to the liver
were included from April 2013
to November 2015.
33. ICG guided robotic surgery
Fluorescence
patterns
Total all tumor tissue showed
uniform fluorescence
all well-differentiated
HCCs
the expression levels of portal uptake transporters of ICG were
well preserved, but functional or morphological biliary
excretion disorders were present, leading to retention of ICG in
cancerous tissues at the time of surgery, following
preoperative intravenous injection.
Partial some tumor tissues
showed fluorescence
Rim the cancer tissues were
negative for
fluorescence, but the
surrounding liver
parenchyma showed
fluorescence
poorly differentiated
HCCs
and CRLM
the portal uptake transporters were downregulated in
cancerous tissues but biliary excretion of ICG by surrounding
non-cancerous hepatic parenchyma was also disordered,
resulting in rim-type fluorescence.
The rim-type fluorescence signal in CRLM has been reported to
be caused by immature hepatocytes with decreased bile
excretion ability that surrounds the tumor
Ishizawa, HepatoBiliary Surg Nutr 2016, 5: 322-328
34. ICG guided robotic surgery
Liu T, Surgical Innovation 2022, 29:532–539
Fluorescent patterns of liver cancers on surgical specimens and their images and overlay
HCC
Fluorescent
Type
Overlay
Total fluorescent type, well-
differentiated HCC
Partial fluorescent type,
moderately differentiated
HCC with haemorrhagic
necrosis
Rim fluorescent type,
poorly differentiated HCC
36. ICG guided robotic surgery
Besides being highly user-dependent, IOUS has the
problem of not detecting lesions that are just below
the surface within the first cm of the liver.
In contrast, NIR light can only penetrate up to 1 cm
into liver parenchyma and thereby fails to detect
deeper tumors.
The combination of IOUS and ICG therefore seems to
increase the detection rate of hepatic metastasis
44. ICG guided robotic surgery
Future of robotic surgery
ICG guided robotic surgery
Future of robotic surgery
ICG guided robotic surgery
45. ICG guided robotic surgery
Progress of NIR-II Fluorescence Technology
NIR-II (1000–1700 nm) fluorescence imaging technology has a longer
emission wavelength than NIR-I (750–900 nm) and can significantly
diminish photon scattering within biological tissues and reduce tissue
autofluorescence and light absorption, leading to significant benefits in
terms of
deeper detection,
higher resolution, and
fidelity.
Liu T, Surgical Innovation 2022, 29:532–539
46. ICG guided robotic surgery
• Patients with liver cancer were enrolled in the study, and then received
preoperative imaging examinations, including enhanced CT, MRI,
ultrasonography and PET.
• Before surgery, the patients were injected with ICG intravenously at a
dose of 0.5 mg kg−1 body weight as a routine preoperative liver function
test.
• One to seven days later, on the day of surgery, the patients received a
laparotomy.
• The liver surface was examined by the integrated NIR-I/II and visible
multispectral imaging instrument and visible and NIR-I/II images were
obtained.
• Tumours were resected by the guidance of ultrasonography and NIR-I
imaging.
• During the resection, NIR-II images were also acquired. After the
operation, visible and NIR-I/II images of the resected specimens were
obtained.
• Pathological examination of the resected tissues was conducted.
First-in-human liver-tumour surgery guided by multispectral fluorescence imaging in the
visible and near-infrared-I/II windows
Hu Z, Nat Biomed Eng 2020;4:259-271
47. ICG guided robotic surgery
Hu Z, Nat Biomed Eng 2020;4:259-271
Intraoperative NIR-I/II fluorescence image-guided tumour resection
For a typical patient
with HCC, guided by
ultrasonography and
the visible light image,
the tumour was
resected and thought
to be completely
removed on the basis
of the experience of
the surgeons.
NIR-II imaging detected
fluorescence signals in
the remaining tissue
sections.
NIR-I imaging
did not reveal
any signals
The fluorescent residual
tissues were further
resected and received
histopathological
examination to verify that
the tissues were HCC.
48. ICG guided robotic surgery
Compared with the current preoperative imaging modalities (ultrasonography, MRI,
CT) and intraoperative imaging techniques (ultrasonography), intraoperative ICG-
based NIR-I/II fluorescence imaging can detect the tumour lesions with no obvious
imaging characteristics.
After laparotomy, intraoperative NIR-I/II fluorescence imaging was able to detect
the lesions missed by preoperative imaging modalities, which can substantially
promote the accuracy of patient staging and management.
During surgery, NIR-I/II imaging can also identify residual lesions that are difficult to
be recognized by surgeons or intraoperative ultrasonography.
Moreover, our imaging study revealed that ICG distributed quite uniformly in well-
differentiated or moderately differentiated tumours, but partial-type and rim-type
distributions were found in the poorly differentiated HCCs, which is consistent with
previously reported findings.
Hu Z, Nat Biomed Eng 2020;4:259-271
50. ICG guided robotic surgery
Molecular imaging is currently a hot research field in the world.
ICG fluorescence imaging technology can
• accurately identify liver tumors and enable real-time surgical navigation to ensure complete tumor resection;
• aid in the determination of tumor differentiation, creating a new target for accurate hepatobiliary surgery.
ICG technology combined with tumor-targeting nanoparticles and the emergence of novel targeted probes greatly
overcome the limitations of ICG.
With probe improvement, the fluorescence imaging system can be combined with other clinical treatment or examination
methods to improve the treatment efficiency of liver cancer.
The rapid development of NIR-II fluorescence imaging is conducive to achieving a more accurate intraoperative navigation
system.
With the advent of precision medicine and the progress of various biotechnology methods, fluorescence imaging technology
will be better developed and applied in the
• diagnosis,
• surgical navigation, and
• treatment of liver cancer.
TAKE HOME MESSAGE
51. ICG guided robotic surgery
As image-guided surgery solutions are quite often technically challenging.
Ethics and regulations provide a healthy translational hurdle to protect patients, while financial aspects
may also constrain development.
Lead compounds and detection device prototypes must be developed and refined in research setting and
often not within the domain of patient care.
While this helps preventing the patient exposure to potentially harmful technologies, it also means that
some approaches can become more ‘technology-driven’ than ‘clinical need-driven’. All developments
should be done with clinical translation in mind and based on real-life unmet surgical needs.
It is extremely challenging to translate laboratory findings to the clinic.
Most chemical and engineering efforts still find applications in multiple settings. The success stories in
the field of image-guided surgery are based on technologies that maximally align with innovations made
in other fields. For example, initial work on fluorescence laparoscopy presented in prostate cancer
surgery was later transferred to breast surgery and the technique is now also implemented during i.e.,
laparoscopic surgery.
FINAL CONSIDERATIONS
52. ICG guided robotic surgery
Gian Luca Grazi
Hepato Biliary Pancreatic Surgery
National Cancer Institute “Regina Elena”, Rome, Italy
gianluca.grazi@ifo.it
www.chirurgiadelfegato.it