Clinical application of indocyanine green fluorescence imaging technology in laparoscopic rectal cancer surgery

Introduction

Rectal cancer is one of the most common malignant tumors in the world, particularly in developed countries, where its incidence and mortality rates are relatively higher. According to World Health Organization (1), rectal cancer ranks high among malignancies in causing cancer-related death, being second only to lung and stomach cancer. The global cancer burden report indicates that rectal cancer is the third most common malignancy in men and the second most common in women (2). The incidence of rectal cancer increases with age and typically occurs in individuals over 50 years old, with higher rates among those aged 60 years and older (3,4). Laparoscopic minimally invasive surgery has gained prominence in abdominal surgery, particularly in colorectal cancer treatment, as it offers unique advantages. When it is combined with indocyanine green (ICG) fluorescence navigation, laparoscopic surgery provides even greater benefit. ICG fluorescence navigation is capable of real-time dynamic imaging, facilitating precise identification of lymph nodes and ensuring proper blood supply to anastomoses, thereby reducing complications, improving treatment outcomes, and extending patient survival (5-7). In this case study, we report the treatment of a 75-year-old male patient with rectal cancer who underwent radical resection via fluorescence laparoscopic surgery (Video 1). We further analyzed the role of ICG fluorescence navigation in improving tumor resection, optimizing vascular assessment, and identifying and removing regional lymph nodes. Through this review, we hope to highlight the profound impact of ICG fluorescence technology in colorectal tumor surgery. We present this article in accordance with the CARE and SUPER reporting checklists (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-644/rc).

Preoperative preparations and requirements

We selected a patient with rectal cancer who was treated at the Fourth Hospital of Hebei Medical University. The patient was a 75-year-old male admitted in March 2023 due to hematochezia lasting for more than 1 month which was accompanied by increased defecation frequency, anal tenesmus, and other discomfort, but no abdominal pain or bloating. His body mass index (BMI) was 20.1 kg/m², and his Eastern Cooperative Oncology Group Performance Status score was 0. He had a history of hypertension, anxiety disorder, and prostatitis for more than 10 years. Rectal digital examination (in the knee-chest position) indicated a normal anal appearance. A finger was inserted about 7 cm into the anus, and no bloodstain was found on the finger cot after withdrawal. Chest and abdominal computed tomography (CT) showed thickening of the rectal wall, consistent with intestinal cancer, no metastases to other organs were observed. Colonoscopy revealed an ulcerative neoplasm at about 10 cm from the anal margin, involving half of the intestinal lumen, while the rest of intestine appeared normal (Figure 1A). Pelvic high-resolution magnetic resonance imaging (MRI) suggested a rectal wall mass consistent with rectal cancer (imaging stage T2N0M0) (Figure 1B). The pathological diagnosis was adenocarcinoma. According to the Chinese Guidelines for the Diagnosis and Treatment of Colorectal Cancer (8), for middle rectal cancer (cT2N0M0) with a small tumor in a patient with a normal BMI, fluorescence navigation–assisted radical resection is recommended for precise diagnosis and treatment. Thorough preoperative preparations were completed in our ward, including a comprehensive assessment of the patient’s physical condition, appropriate bowel cleansing, nutritional support, psychological counseling, and other treatments. All procedures performed in this study complied with the ethical standards of the relevant institutional and/or national research committees and adhered to the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this manuscript, accompanying images, and the video. A copy of the written consent is available for review by the editorial office of this journal.

Figure 1 Preoperative colonoscopy and pelvic MRI. (A) Colonoscopy image showing an ulcerative neoplasm at 10 cm from the anal margin. (B) Preoperative pelvic MRI examination of rectal tumor (the arrow indicates a rectal tumor). MRI, magnetic resonance imaging.

Step-by-step description of the procedure

In March 2023, after a comprehensive evaluation, the patient underwent total laparoscopic fluorescence navigation natural orifice specimen extraction surgery (NOSES) IV at the Fourth Hospital of Hebei Medical University under general anesthesia. A 4K fluorescent endoscope (FLI-20A; Nuoyan Medical Devices, Nanjing, China) was used and was accompanied by the application of ICG (dilution 2.5 mg/mL) fluorescent tracers to facilitate switching between white-light, fluorescent, and fusion image modes in minimally invasive endoscopic surgery. With a simple one-button operation, surgeons could easily switch between lymph, organ, and tumor imaging modes and customize settings as needed. In addition, the camera handle allowed for easy photography and video recording, while the host workstation had advanced functions such as color gradient image display and quantitative analysis of fluorescence intensity. The entire surgical team consisted of experienced surgeons, anesthesiologists, and nurses to ensure the smooth progress of the operation.

The patient was placed in the Trendelenburg position, with the head lower than the horizontal plane and the feet higher than the head. The right side was tilted slightly lower than the left side. The positioning of surgical team during the operation was as follows: the chief surgeon stands on the right side of the patient with a mirror support hand, and the assistant stands on the left side. A traditional five-port technique was used: first, a 10-mm trocar was placed at the upper edge of the umbilicus to establish a pneumoperitoneum at 13 mmHg. A 30° laparoscopic lens was inserted through the trocar, ensuring avoidance of the deep inferior epigastric artery. A 12-mm trocar was placed two fingerbreadths from the right anterior superior iliac spine as the main operating port for the chief surgeon; a 5-mm trocar was placed at the intersection of the right midclavicular line and the umbilical horizontal line as an auxiliary operating port; another 5-mm trocar was placed at the intersection of the left rectus abdominis (lateral margin) and the umbilical horizontal line as the main operating port for the assistant; and finally, a third 5-mm trocar was placed at the outer one-third as an auxiliary operating port. Intraoperative exploration revealed no metastasis in the abdominal organs, and the tumor was located in the rectum, 3 cm above the peritoneal reflection. Before the operation, 0.2 mL of ICG (H20055881; Rui Du, Dandong, China) was injected into the subserosa at three points 1 cm from the tumor margin. During the operation, the injected fluorescent substance made the surrounding lymph nodes appear green under the fluorescent laparoscope, helping surgeons accurately locate the lymph nodes (Figure 2).

Figure 2 Subserosal injection of ICG around the tumor and subsequent fluorescence visualization of peritumoral lymph nodes. ICG, indocyanine green.

The operation involved a medial approach with an ultrasonic scalpel (Ulthera, Inc., Mesa, AZ, USA), with the sacral promontory serving as the entry point and the yellow–white junction line serving as a reference (Figure 3A). During the operation, fusion imaging and lymphatic fluorescence imaging techniques were combined to precisely track the location of mesenteric lymph nodes (Figure 3B). The sigmoid mesentery was incised from the caudal-to-cranial direction, and a loose space was exposed; that is, the fusion fascia space (Toldt’s space) between the left mesocolon and Gerota’s fascia. The assistant’s left intestinal forceps continued to pull the upper rectum ventrally, and the right grasping forceps held the inferior mesenteric artery (IMA) pedicle, maintaining tension cranially and ventrally. The chief surgeon carefully expanded Toldt’s space along the anatomical plane using a combination of blunt and sharp dissection until reaching the root of the IMA, which was then followed by dissection of the IMA 253 lymph nodes. Dissection was carried distally to the bifurcation of the left colic artery (ICA) from the IMA and proximally along the ICA for the dissection of the lymph nodes between the left colic vessels, IMA, and aortic angle (group 253). After lymph node dissection, the IMA was dissected distally and exposed up to the ICA, which was preserved. The superior rectal artery was transected, and the inferior mesenteric vein (IMV) was dissected at the same level as the arterial transection (Figure 4A). After vein transection, an ultrasonic scalpel was used for rapid and precise dissection to expand Toldt’s space, with special attention being paid to protecting the genital vessels, hypogastric plexus nerves (lumbar spinal nerves), and ureters (superior hypogastric plexus) (Figure 4B).

Figure 3 Intraoperative images. (A) The arrows indicate that the first incision is made through the medial approach at the yellow-white junction of the sacral angle. (B) The arrows indicate the protrusion of lymph nodes and microvessels after the injection of indocyanine green.

Figure 4 Intraoperative images. (A) The arrow indicates the IMA, the LCA, and inferior mesenteric vein (LCV). (B) The arrows indicate the distribution of the LUR and the upper abdomen and lower costal nerve (SHP), respectively. IMA, inferior mesenteric artery; LCA, left colonic artery; LCV, left colonic vein; LUR, left ureter; SHP, superior hypogastric plexus.

Next, beginning from the level of the sacral promontory and along the rectal mesentery, the retrorectal space between the rectal mesentery and the presacral fascia was entered; the surgical field was then expanded caudally, with the rectosacral fascia being incised (Figure 5A). Subsequently, the retrorectal space was expanded laterally, with the posterior space being used as a reference for the gradual freeing of the surrounding rectal space and transection of the bilateral rectal lateral ligaments. At this time, it was critical to protect the bilateral pelvic nerves (Figure 5B). Finally, the peritoneal reflection on both sides of the rectum was incised caudally, and the rectum was further freed distally along the peritoneal reflection area between the rectum and bladder. When the operation reached about the height of the prostate, the assistant used two instruments to grasp and fix the proximal intestine, which could be the lower sigmoid colon or the upper rectum, to fully tension the distal rectum for processing. Subsequently, a 5-cm-long black silk thread was used to mark and locate the distal end of the tumor. The rectal mesentery was then incised with an ultrasonic scalpel to fully expose the intestinal wall. Immediately after, an endoscopic linear cutting stapler was used to close and transect the exposed rectal tube, forming the blind end of the proximal intestine to be resected and the blind end of the distal intestine to be anastomosed. After the above steps were completed, the proximal intestine was exposed: a 5-cm silk thread was used as a reference, and 10 cm was measured on the proximal intestine which was marked for transection. The assistant then used the left intestinal forceps and the right grasping forceps to fix and pull both sides of the intestine to be transected. The chief surgeon used the left grasping forceps to hold the residual sigmoid mesentery to form a triangular traction posture. The chief surgeon’s right hand held an ultrasonic scalpel and other electrical instruments to incise the sigmoid mesentery along the preplanned incision line until the intestinal wall was reached. Another assistant irrigated and disinfected the distal rectum, and the chief surgeon used electrical instruments to incise the closed end of the distal rectum to open the intestine. The assistant inserted a sterile plastic tube sleeve from the anus into the rectum with an ovum forceps, then placed the stapler anvil from the sterile specimen bag into the intestine, incised the intestinal wall at the exposed sigmoid colon, placed the stapler anvil into the intestinal cavity (29-mm circular stapler), and then used an endoscopic linear cutting stapler to close and transect the exposed sigmoid colon. With the cooperation of the chief surgeon, the assistant placed the fully freed rectal specimen into the sterile plastic tube sleeve, tightened the white edge band at the end of the sterile plastic tube sleeve, and then pulled the specimen out of the body through the rectal lumen to complete the specimen extraction. Following this, the rectal stump was closed again with an endoscopic linear cutting stapler. Another assistant slowly inserted the stapler from the anus and under direct laparoscopic vision, adjusted the knob to extend the central rod, which penetrated near the midpoint of the closed line of the distal intestinal blind end until the green mark of the central rod was fully exposed. The anvil was clamped with anvil-holding forceps, docked, and locked with the central rod of the stapler. The knob was then retracted to draw the anvil and the stapler head close to one another until the indicator window showed that a safe range was reached. After it was ensured that the intestinal tubes on either side of the anastomosis were not twisted and no other tissues were clamped, the stapler was unlocked and fired to complete the anastomosis.

Figure 5 Intraoperative images. (A) The arrows indicate the posterior rectal space between the mesorectal and the presacral fasciae. (B) The arrows indicate the distribution of the left and right pelvic nerves.

After the anastomosis, 2 mL of ICG was again injected into the peripheral vein. After 60 seconds, the blood supply of the proximal intestine and mesentery was observed with a fluorescent laparoscope, and the blood supply around the anastomosis was good (Figure 6). An abdominal drainage tube was then placed, and the operation was successfully completed. After the effects of anesthesia subsided, the patient was safely returned to the ward and provided with level-one care. Vital signs such as temperature, pulse, blood pressure, and respiration were monitored and recorded. The patient’s bowel movement and intestinal peristalsis were observed, and the wound was kept clean, with the dressings being changed in a timely manner. Additionally, the patient’s dietary recovery and fluid balance were monitored, with measures taken to prevent complications such as deep vein thrombosis, pulmonary infections, and intestinal infections. Psychological support was provided as necessary, depending on the patient’s emotional state.

Figure 6 The green fluorescence mode (A), high-purity white light mode (B), the and the black-and-white fluorescence mode (C). The arrows indicate the anastomotic site with adequate blood supply.

Postoperative considerations and tasks

In the resected specimen, the upper margin of the tumor was 10 cm from the upper incision margin, the lower margin was 5 cm from the lower incision margin, and the tumor volume was about 2 cm × 2 cm × 1 cm, accounting for about one-fourth of the intestinal lumen volume, and the lymph nodes were dissected (Figure 7). The postoperative pathological report indicated grade II adenocarcinoma, tumor invasion of the deep muscular layer, low-grade tumor budding, and a negative circumferential resection margin and clinical upper and lower resection margins; there was no vascular tumor thrombus or nerve invasion. The lymph node metastasis status was as follows: 0/6 paracolic lymph nodes, 0/2 mesenteric lymph nodes, 0/4 mesenteric root lymph nodes, and 0/2 group 253 lymph nodes. The total operation time was 120 minutes. Postoperatively, the patient recovered smoothly, could get out of bed and start eating clear liquid diet on the first postoperative day, and then transitioned to liquid diet. First flatus and defecation occurred on the second day, the pelvic drainage tube was removed on the fifth day, and the patient finally recovered and was discharged. The patient was pleased and reassured about the surgical process and was especially trusting of and grateful for the application of ICG imaging technology, which he believed ensured the accuracy and success of the operation. Furthermore, he recovered well, felt relaxed and optimistic, experienced reduced pain and an accelerated recovery, and was hopeful for a healthy future life. Postoperative follow-up instruction was conducted, with the patient being advised to follow up regularly for monitoring of recurrence, metastasis, or other health problems. Follow-up usually includes physical examinations, imaging examinations (e.g., CT, MRI, and colonoscopy), and blood tests (e.g., carcinoembryonic antigen and other tumor markers) to ensure the early detection of abnormal signs and their management in a timely fashion. The follow-up frequency is high in the first 2 years—at once every 3 months—and then gradually decreases. As of the time of writing, the patient’s follow-up results have been normal, and he is in good health.

Figure 7 Postexcision rectal specimen with the tumor and anatomical lymph nodes displayed.

Tips and pearls

In this case, the patient’s tumor was staged as T2. Preoperatively, precise ICG subserosal injection was used to successfully locate the rectal tumor and plan the length and range of the bowel resection, ensuring complete tumor removal. The video clearly shows that, with the help of fluorescence guidance, the boundary between the IMA and the ICA was accurately identified. During the surgery, the ICA was preserved to maintain blood supply, while a thorough radical lymph node dissection was performed. The application of ICG fluorescence technology allowed for clearer visualization of lymph nodes and lymphatic vessels, significantly shortening the dissection time. A total of 253 groups of lymph nodes and mesenteric lymph nodes were precisely located and completely removed, ensuring thorough and safe dissection, while greatly increasing the detection rate of lymph nodes. This technology not only optimized the surgical steps but also provided more reliable data for postoperative pathological evaluation. Additionally, in this case, ICG intravenous injection was used to monitor the vascular perfusion of the bowel after anastomosis, precisely evaluating bowel blood supply to effectively prevent anastomotic leakage. This greatly improved the surgical outcome and quality, shortened the operation time, reduced surgical risks, and provided the patient with a safer and more efficient treatment experience.

The surgery utilized the Nanjing Nuoyuan 4K fluorescence laparoscopic system, which is equipped with a real-time synchronized light source adjustment function. This system automatically adjusts the laser intensity according to the surgical conditions, ensuring stable imaging quality even if the instrument shifts. The system demonstrated high sensitivity and excellent visualization, enabling clear identification of even small lymph nodes, thus helping achieve more precise and comprehensive lymph node dissection. At the same time, it aided in performing the procedure along the correct anatomical planes, providing excellent nerve protection and ensuring optimal functional recovery postoperatively. The use of this system also effectively shortened the operation time, accelerated patient recovery, and reduced the length of hospital stay.

In summary, the laparoscopic rectal cancer radical surgery combined with fluorescence-guided technology provided a more precise and efficient treatment approach, significantly improving postoperative prognosis and quality of life. This technology not only enhanced the precision and safety of the surgery but also opened new directions for minimally invasive treatment of colorectal cancer, with broad clinical application and promotion prospects.

Discussion

ICG fluorescence navigation technology has become an important auxiliary technique in laparoscopic rectal cancer surgery, significantly improving the accuracy and safety of the surgery (9). By visualizing the tumor boundary in real time, ICG can help surgeons to accurately remove tumors, ensuring a clear surgical margin and reducing the risks of incomplete resection and cancer recurrence (10). In addition, ICG fluorescence technology also enhances the safety of the anastomosis via the real-time assessment of blood flow at the anastomosis, thereby reducing complications such as anastomotic leakage and ischemia and significantly lowering the incidence of postoperative complications (11,12). These complications are major contributors to morbidity and mortality in colorectal surgery. Therefore, the use of ICG can considerably improve the success rate of surgery and the prognosis of patients (13).

In addition, ICG fluorescence also has significant advantages in lymph node identification. Fluorescence guidance allows surgeons to more accurately identify and resect metastatic lymph nodes, enhance the effect of lymph node dissection, and increase the accuracy of postoperative staging (14,15). Accurate lymph node dissection is crucial for optimizing the prognosis of patients with rectal cancer, as it helps clinicians determine whether further adjuvant therapy is needed and guides personalized treatment plans (16,17).

Although ICG fluorescence technology has demonstrated significant advantages in clinical practice, its application still faces certain limitations and challenges. First, ICG fluorescence navigation relies on specialized equipment, requiring high-performance fluorescence imaging systems, and places high demands on operative precision as well as the accurate interpretation of images. Surgeons often encounter a learning curve in mastering this technique, which may limit its widespread adoption in the short term. In addition, the effectiveness of ICG fluorescence can be influenced by multiple factors, including patient-specific variations, the timing of dye injection, imaging quality, and operator experience, meaning that its clinical performance may not achieve optimal results in all patients. On the other hand, although some studies suggest that ICG may increase the number of harvested lymph nodes, whether this increase can truly translate into improved oncological outcomes remains controversial, and clear evidence demonstrating that ICG enhances the detection rate of positive lymph nodes is still lacking (18,19).

The cost-effectiveness of using ICG fluorescence technology is also a key consideration. Although this technology can significantly enhance the safety of the surgery and postoperative prognosis, the use of the related equipment and fluorescent agents increases the overall cost of the surgery. For hospitals and patients, ICG fluorescence navigation may impose a higher economic burden (20). However, in the long term, by reducing postoperative complications such as anastomotic leakage and ischemia and lowering the readmission rate, the use of ICG can help reduce hospital stays and treatment duration (21,22).

ICG fluorescence navigation technology requires further development and optimization. Ongoing clinical research and technological innovations will improve its accuracy and widen its applicability. Specifically, large-scale randomized controlled trials comparing ICG fluorescence-guided surgery with traditional laparoscopic techniques should be conducted to obtain more evidence. These studies will clarify the practical clinical benefits, limitations, and indications of ICG fluorescence technology. Furthermore, with technological advancements, the application of ICG on robotic platforms has become increasingly widespread. The system integrates ICG technology, allowing easy switching to ICG mode without any additional equipment, providing more precise fluorescence imaging, which further enhances diagnostic accuracy and operational convenience, thereby offering rectal cancer patients safer and more effective treatment options (23).

Finally, it should be noted that the application prospects of ICG fluorescence navigation technology in laparoscopic rectal cancer surgery are broad. However, certain technical and economic challenges regarding its more widespread application remain. With the continuous improvement of related technologies and the accumulation of clinical practice, ICG fluorescence navigation is expected to become an indispensable technique in rectal cancer surgery, providing patients with a more accurate and safer treatment experience.

Conclusions

ICG fluorescence navigation technology has played an important role in laparoscopic rectal cancer surgery. By providing real-time intraoperative guidance, it has enhanced the accuracy and safety of surgery. With this tool, surgeons can assess tumor boundaries, blood supply, and lymphatic pathways, and it has been proven capable of improving surgical outcomes, reducing postoperative complications, and providing more accurate postoperative staging. With the continuous development and wide application of this technology, ICG fluorescence navigation will play an increasingly critical role in the surgical treatment of rectal cancer.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE and SUPER reporting checklists. Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-644/rc

Peer Review File: Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-644/prf

Funding: This work received funding from the Medical Science Research Project Plan of the Hebei Provincial Health (commission project Nos. 20210027 and 20220138) and the 2022–2023 National Anticancer Drug Clinical Application Monitoring Network Oncology Standardized Diagnosis and Treatment Young and Middle-aged Research Fund Project (project No. DSS-YSF-2023003).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-644/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study complied with the ethical standards of the relevant institutional and/or national research committees and adhered to the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this manuscript, accompanying images, and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Ilie DS, Şerbanescu MS, Ionovici N, et al. Colorectal Cancer in County Durham-England a Clinical and Statistical Study. Curr Health Sci J 2021;47:338-47. [PubMed]
2. Zhang X, Yang L, Liu S, et al. Interpretation on the report of global cancer statistics 2022. Zhonghua Zhong Liu Za Zhi 2024;46:710-21. [PubMed]
3. Cohen D, Rogers C, Gabre J, et al. The Young: Early-Onset Colon Cancer. Clin Colon Rectal Surg 2025;38:173-8. [Crossref] [PubMed]
4. Nie JX, Xie Q, Yuan Y, et al. Rising Incidence of Total and Early-Onset Colorectal Cancer: A Global Perspective on Burden, Risk Factors, and Projections to 2031. J Gastrointest Cancer 2025;56:138. [Crossref] [PubMed]
5. Ye Y, Zeng X, Luo Z, et al. Enhanced photostability and targeting ability of hollow mesoporous manganese-based nanocarriers for NIR-II fluorescence image-guided surgery and photothermal therapy. J Colloid Interface Sci 2025;698:138094. [Crossref] [PubMed]
6. Yi X, Hu H, Shi H, et al. The role of indocyanine green fluorescence angiography in the perioperative period for patients after colorectal surgery: a meta-analysis of propensity score-matched studies with trial sequential analysis. Surg Endosc 2025;39:4899-918. [Crossref] [PubMed]
7. Litchinko A, Meyer J, Buhler L, et al. Fluorescence indocyanine green (ICG) for sentinel-lymph-node mapping in colorectal cancer: a systematic review. Langenbecks Arch Surg 2025;410:202. [Crossref] [PubMed]
8. Chinese College of Surgeons, Chinese Society of Gastrointestinal Surgery, Chinese Society of Colorectal Surgery, et al. Chinese guidelines for diagnosis and comprehensive treatment of colorectal liver metastases (2023 edition). Chinese Journal of Digestive Surgery 2023;22:1-28.
9. Li H, Xie X, Du F, et al. A narrative review of intraoperative use of indocyanine green fluorescence imaging in gastrointestinal cancer: situation and future directions. J Gastrointest Oncol 2023;14:1095-113. [Crossref] [PubMed]
10. Lucarini A, Guida AM, Orville M, et al. Indocyanine green fluorescence angiography could reduce the risk of anastomotic leakage in rectal cancer surgery: a systematic review and meta-analysis of randomized controlled trials. Colorectal Dis 2024;26:408-16. [Crossref] [PubMed]
11. Ryu S, Imaizumi Y, Goto K, et al. The Effect of Multifaceted Anastomotic Leakage Prevention via ICG and SST for Lower Rectal Anastomosis. In Vivo 2024;38:2973-80. [Crossref] [PubMed]
12. Gach T, Bogacki P, Orzeszko Z, et al. Fluorescent ICG angiography in laparoscopic rectal resection - a randomized controlled trial. Preliminary report. Wideochir Inne Tech Maloinwazyjne 2023;18:410-7. [Crossref] [PubMed]
13. Watanabe J, Takemasa I, Kotake M, et al. Blood Perfusion Assessment by Indocyanine Green Fluorescence Imaging for Minimally Invasive Rectal Cancer Surgery (EssentiAL trial): A Randomized Clinical Trial. Ann Surg 2023;278:e688-94. [Crossref] [PubMed]
14. Wan J, Wang S, Yan B, et al. Indocyanine green for radical lymph node dissection in patients with sigmoid and rectal cancer: randomized clinical trial. BJS Open 2022;6:zrac151. [Crossref] [PubMed]
15. Lin W, Li Q, Sheng J, et al. Quantitative analysis of peri-intestinal lymph node metastasis using indocyanine green fluorescence imaging technology. Medicine (Baltimore) 2024;103:e39240. [Crossref] [PubMed]
16. Varanese M, Arcieri S, Lauro A, et al. Indocyanine Green Tattooing During Colonoscopy as a Guide to Laparoscopic Colorectal Cancer Surgery: A Literature Review. Surg Innov 2024;31:103-10. [Crossref] [PubMed]
17. Dai ZY, Shen C, Mi XQ, et al. The primary application of indocyanine green fluorescence imaging in surgical oncology. Front Surg 2023;10:1077492. [Crossref] [PubMed]
18. Pampiglione T, Chand M. Enhancing colorectal anastomotic safety with indocyanine green fluorescence angiography: An update. Surg Oncol 2022;43:101545. [Crossref] [PubMed]
19. Kehagias D, Lampropoulos C, Bellou A, et al. The use of indocyanine green for lateral lymph node dissection in rectal cancer-preliminary data from an emerging procedure: a systematic review of the literature. Tech Coloproctol 2024;28:53. [Crossref] [PubMed]
20. Liu RQ, Elnahas A, Tang E, et al. Cost analysis of indocyanine green fluorescence angiography for prevention of anastomotic leakage in colorectal surgery. Surg Endosc 2022;36:9281-7. [Crossref] [PubMed]
21. Safiejko K, Tarkowski R, Kozlowski TP, et al. Safety and Efficacy of Indocyanine Green in Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis of 11,047 Patients. Cancers (Basel) 2022;14:1036. [Crossref] [PubMed]
22. Zhang W, Che X. Effect of indocyanine green fluorescence angiography on preventing anastomotic leakage after colorectal surgery: a meta-analysis. Surg Today 2021;51:1415-28. [Crossref] [PubMed]
23. Faber RA, Meijer RPJ, Droogh DHM, et al. Indocyanine green near-infrared fluorescence bowel perfusion assessment to prevent anastomotic leakage in minimally invasive colorectal surgery (AVOID): a multicentre, randomised, controlled, phase 3 trial. Lancet Gastroenterol Hepatol 2024;9:924-34. [Crossref] [PubMed]

(English Language Editor: J. Gray)