Search Results (12)

Background/Objectives: Robotic gastrectomy (RG) for gastric cancer requires structured implementation to ensure oncological safety, particularly in Western centers with lower case volumes. Indocyanine green (ICG)-guided near-infrared lymphography may facilitate adequate lymphadenectomy and reliable tumor localization. We report our stepwise institutional introduction of RG and evaluate the perioperative outcomes and diagnostic accuracy of ICG-guided lymphography. Methods: All consecutive patients who underwent curative-intent RG at the University Medical Center Ljubljana between June 2022 and September 2025 were retrospectively analyzed. The implementation followed a structured stepwise approach, beginning with subtotal gastrectomy and progressing to total gastrectomy after formal training at Severance Hospital, Yonsei University Health System, under the mentorship of Prof. Woo Jin Hyung. ICG was administered endoscopically the day before surgery for tumor localization and intraoperative lymphatic mapping. The operative learning curve was assessed by CUSUM analysis, segmented regression, and bootstrapped plateau estimation. Results: Thirty-eight patients underwent RG (17 subtotal and 21 total). R0 resection was achieved in 100% of cases. The conversion rate was 2.6%. Major complications (Clavien–Dindo ≥ IIIb) occurred in six patients (15.8%). The 30-day mortality rate was 0%, and the 90-day mortality rate was 2.6%. Bootstrapped plateau operative times were 321.2 min (95% Bias-corrected and accelerated confidence interval (BCa CI): 278.4–344.1) for subtotal and 413.5 min (95% BCa CI: 378.1–476.1) for total gastrectomy, with the steepest learning phase confined to the first 2–4 cases. ICG was used in 23 patients. In a validation subset of five patients (259 lymph node stations), the sensitivity and negative predictive value were both 100%, with zero false negatives in 57 ICG-negative stations. Conclusions: RG can be safely introduced using a structured, stepwise strategy supported by training at a high-volume expert center. ICG-guided lymphography demonstrated 100% sensitivity for tumor-draining nodal basins in a small validation cohort (n = 5), supporting the feasibility of the technique during program introduction and warranting prospective evaluation in larger series. Full article

Introduction: Robotic gastrectomy is increasingly used in the surgical management of gastric cancer. Indocyanine green (ICG) near-infrared fluorescence imaging has emerged as a technique that enables real-time visualization of lymphatic drainage pathways, potentially facilitating more precise and individualized lymph node dissection. However, the clinical value of ICG-guided fluorescent lymphography during robotic gastrectomy remains incompletely established. Methods: A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. PubMed, Embase, Scopus, and the Cochrane Library were searched from database inception to 31 January 2026 for comparative studies evaluating ICG-guided fluorescent lymphography versus standard robotic gastrectomy for gastric cancer. Statistical analyses were performed using R (version 4.4.2) and the meta package. Results: Six studies, including 406 patients, met the inclusion criteria. Use of ICG was associated with a higher number of retrieved lymph nodes (mean difference [MD] 8.48; 95% CI 4.61–12.36; p = 0.001; I² = 55.5%). Operative time was modestly shorter in the ICG group (MD −10.84 min; 95% CI −21.08 to −0.61; p = 0.038). There were no significant differences in intraoperative blood loss (MD −4.02 mL; p = 0.289), length of hospital stay (MD −0.82 days; p = 0.131), or postoperative complications (odds ratio 0.83; 95% CI 0.46–1.49; p = 0.534). Conclusions: ICG-guided fluorescence imaging during robotic gastrectomy is associated with increased lymph node retrieval and a small reduction in operative time without evidence of increased perioperative morbidity. Larger prospective studies are required to confirm these findings and to evaluate long-term oncologic outcomes. Full article

Sentinel lymph node mapping is increasingly used in canine and feline oncology and often involves the combined use of visible dyes and fluorescent tracers. However, the effect of methylene blue on the fluorescence of indocyanine green during near-infrared imaging remains unclear. This explorative study aimed to quantitatively and qualitatively assess potential fluorescence quenching in solutions of methylene blue–indocyanine green at different ratios in three near-infrared imaging modalities (overlay, color map, contrast). Four solutions were prepared: 100%/0%, 75%/25%, 50%/50%, and 25%/75% indocyanine green/methylene blue. The fluorescence intensity of the four solutions was quantitatively measured in vitro using near-infrared imaging. Subsequently, four lymphographies, one for each solution, were performed from the metatarsal region of feline cadavers. Observers with varying levels of experience evaluated lymphographic images. Methylene blue caused a concentration-dependent reduction in fluorescence both at the quantitative evaluation and qualitative lymphography interpretation. Despite this reduction, fluorescence remained sufficient in cadavers for accurate identification of lymph nodes, and observer experience did not significantly affect interpretation, except for the color map mode. Because methylene blue-dominant solutions showed a greater quenching effect on indocyanine green fluorescence, clinicians should favor indocyanine green-dominant mixtures. This approach may preserve fluorescence performance, maintaining the surgical guidance benefits of methylene blue. Future confirmatory studies should include a substantially larger number of specimens to allow appropriate statistical comparisons and to better account for inter-individual variability. Full article

Background: Lipedema is a progressive adipofascial disorder marked by painful nodular fat deposition that is often mistaken for obesity. While tumescent liposuction reduces limb volume with relative lymphatic safety, persistent large, painful lobules frequently remain, and excisional strategies risk iatrogenic lymphatic injury. We evaluated the application of intraoperative indocyanine green (ICG) lymphography to identify and preserve lymphatic channels during debulking surgery for symptomatic lipedema. Methods: We conducted a single-center case series (University of Pittsburgh Medical Center, July 2023–December 2024) of adults with lipedema refractory to conservative therapy who underwent a selective dermato-lipectomy (lobule/skin excision) with or without tumescent liposuction. Patients with clinical lymphedema or dermal backflow in ICG were excluded. Near-infrared ICG (SPY-PHI) was used for pre-incision mapping and real-time intraoperative guidance; lymphatic trajectories were marked and spared during lobule excision. Primary measures included dermal backflow patterns and lymph node transit time; secondary outcomes were complications and symptom burden (Lymphedema Life Impact Scale, LLIS) through ≥24 months. Results: Eight patients (five female/three male; mean age 49.5 ± 14.4 years; median BMI 52.65 kg/m²) underwent ICG-guided surgery. Preoperatively, linear lymphatic patterns were visualized up to the knee in all patients, but dermal backflow patterns could not be visualized in 83% from the level of the knee to the groin. Still, 67% demonstrated inguinal nodal uptake (mean transit 24 min), suggesting preserved lymphatic transport. All cases achieved intraoperative confirmation of intact lymphatic flow after debulking. The mean liposuction aspirate was 925 ± 250 mL per lower extremity; the mean excision mass was 2209 ± 757 g per lower extremity. Complications included two superficial cellulitis events (25%) and one wound dehiscence (12.5%); no hematomas or skin necrosis occurred. No patient developed clinical or imaging evidence of iatrogenic lymphedema during follow-up. Conclusions: Intraoperative ICG lymphography is a practical adjunct for lymphatic-sparing debulking of symptomatic lipedema, enabling real-time identification and preservation of superficial collectors while addressing focal lobules. This hybrid approach—targeted tumescent liposuction followed by ICG-guided superficial dermato-lipectomy—was associated with meaningful symptom improvement and a low morbidity in this early series. Full article

Introduction: Axillary reverse mapping (ARM) aims to reduce the risk of breast cancer-related lymphedema (BCRL) by preserving and limiting dissection of arm-draining lymphatics. The ideal type of dye and the location of injection, which maximize the sparing of lymphatics and improve outcomes of immediate lymphatic reconstruction (ILR), remain under-studied. The current literature reports inconsistent visualization of lymphatics using blue dye alone, whereas indocyanine green (ICG) near-infrared (NIR) lymphography has shown improved rates. However, optimized dual-dye workflows integrating breast–plastics co-surgery are lacking. Methods: A retrospective review of patients who underwent ILR following ALND for breast cancer between June 2021 and June 2023 was conducted. Patients who underwent ARM using our dual-dye technique were included, utilizing intradermal injections of indocyanine green (ICG) into the wrist and isosulfan blue (ISB) into the upper arm. Axillary reverse mapping channels were categorized by the type of dye used to visualize. Dye injection site, number of lymphatic channels visualized, channel diameter (mm), time-to-first channel, coordinates relative to fixed landmarks, ILR configuration, and pathologic findings were reviewed. Mann–Whitney U tests were used to compare channel visualization rates between types of dye. Results: Of 26 patients, 21 underwent dual-dye mapping and were included. A total of 115 ARM channels were identified: 99 (86%) via ICG and 29 (25%) via ISB. A total of 64 lymphaticovenous anastomoses were performed (mean: 2.46 per patient). Both dyes were identified in the axilla in only 11.7% of patients. At the end of the study, the lymphedema rate was 12%. Conclusions: We developed a reproducible dual-dye ARM technique for ALND with planned ILR, reducing lymphedema risk while maintaining oncologic safety. Dual-dye mapping reveals that proximal and distal lymphatics exhibit both overlapping and divergent drainage to axillary nodes. ICG’s higher axillary detection rate may reflect true anatomical differences or dye properties. These findings support the need for individualized lymphatic mapping during breast cancer surgery to guide preservation techniques and reduce the risk of BCRL. Full article

Background/Objectives: Microsurgery employs techniques requiring optical magnification and specialized instruments to operate on small anatomical structures, including small vessels. These methods are integral to plastic surgery, enabling procedures such as free tissue transfer, nerve reconstruction, replantation, and lymphatic surgery. This paper explores the historical development, advancements, and current applications of microsurgery in plastic surgery. Methods: The databases MEDLINE (via PubMed) and Web of Science were selectively searched with the term “(((microsurgery) OR (advances)) OR (robotic)) OR (AI)) AND (((lymphatic surgery) OR (peripheral nerve surgery)) OR (allotransplantation))” and manually checked for relevance. Additionally, a supplementary search among the references of all publications included was performed. Articles were included that were published in English or German up to June 2024. Results: Modern microsurgical techniques have revolutionized plastic surgery, enabling precise tissue transfers, improved nerve reconstruction, and effective lymphedema treatments. The evolution of robotic-assisted surgery, with systems like da Vinci and MUSA, has enhanced precision and reduced operative times. Innovations in imaging, such as magnetic resonance (MR) lymphography and near-infrared fluorescence, have significantly improved surgical planning and outcomes. Conclusions: The continuous advancements in microsurgery, including supermicrosurgical techniques and robotic assistance, have significantly enhanced the capabilities and outcomes of plastic surgery. Future developments in AI and robotics promise further improvements in precision and efficiency, while new imaging modalities and surgical techniques expand the scope and success of microsurgical interventions. Full article

Cancer is the leading cause of death in companion animals. The evaluation of locoregional lymph nodes, known as lymph node mapping, is a critical process in assessing the stage of various solid tumors, such as mast cell tumors (MCTs), anal gland anal sac adenocarcinoma, melanoma, and mammary gland adenocarcinoma. MCTs are among the most prevalent skin malignancies in dogs. Staging is used to describe the extent of neoplastic disease, provide a framework for rational treatment planning, and evaluate treatment results. The aim of this review is to present the current knowledge on sentinel lymph node (SLN) mapping in canine MCTs, its influence on treatment decisions and prognosis, as well as the advantages and limitations of different SLN techniques currently available in veterinary oncology. A search methodology was adopted using the PubMed, Scopus, and Google Scholar databases. Critical analyses of up-to-date research have shown that lymphoscintigraphy can achieve a lymph node detection rate of between 91 and 100%. This method is becoming increasingly recognized as the gold standard in both human and veterinary medicine. In addition, initial studies on a limited number of animals have shown that computed tomographic lymphography (CTL) is highly effective in the SLN mapping of MCTs, with detection rates between 90 and 100%. The first study on contrast-enhanced ultrasound (CEUS) also revealed that this advanced technique has up to a 95% detection rate in canine MCTs. These methods provide non-ionizing alternatives with high detection capabilities. Furthermore, combining computed tomography and near-infrared fluorescence (NIR/NIR-LND) lymphography is promising as each technique identifies different SLNs. Indirect lymphography with Lipiodol or Iohexol is technically feasible and may be also used to effectively detect SLNs. The integration of these mapping techniques into routine MCT staging is essential for enhancing the precision of MCT staging and potentially improving therapeutic outcomes. However, further clinical trials involving a larger number of animals are necessary to refine these procedures and fully evaluate the clinical benefits of each technique. Full article

Lymphedema is a progressive condition. Its therapy aims to reduce edema, prevent its progression, and provide psychosocial aid. Nonsurgical treatment in advanced stages is mostly insufficient. Therefore—in many cases—surgical procedures, such as to restore lymph flow or excise lymphedema tissues, are the only ways to improve patients’ quality of life. Imaging modalities: Lymphoscintigraphy (LS), near-infrared fluorescent (NIRF) imaging—also termed indocyanine green (ICG) lymphography (ICG-L)—ultrasonography (US), magnetic resonance lymphangiography (MRL), computed tomography (CT), photoacoustic imaging (PAI), and optical coherence tomography (OCT) are standardized techniques, which can be utilized in lymphedema diagnosis, staging, treatment, and follow-up. Conclusions: The combined use of these imaging modalities and self-assessment questionnaires deliver objective parameters for choosing the most suitable surgical therapy and achieving the best possible postoperative outcome. Full article

There is increasing evidence on the utility of sentinel lymph node (SLN) biopsy (SLNB) for the staging of dogs with various malignancies; however, comparable information is missing in cats. This multi-institutional study aims at reporting the feasibility and detection rate of SLNB guided by lymphoscintigraphy and the blue dye or near-infrared fluorescent lymphography (NIRF-L) in cats with solid tumors. In total, 12 cats presented with 14 solid malignancies that underwent curative-intent surgical excision of the primary tumor and SLNB were retrospectively enrolled. The mapping technique used, location and number of SLN, correspondence with the regional lymph node (RLN), and histological status of the SLN were retrieved. The detection rate and complications of SLNB were also recorded. NIRF-L was performed in 64.3% of tumors and lymphoscintigraphy in 35.7%. The detection rate was 100% for both techniques. The SLN did not correspond (fully or partially) to the RLN in 71.4% of cases, with multiple SLN being excised in 9/14 tumors. No complications related to SLNB were recorded. At histopathology, metastases were identified in 41.7% of cats, all with mast cell tumors (MCT). SLNB guided by NIRF-L or lymphoscintigraphy is feasible and safe in cats with solid tumors and should be suggested for correct tumor staging in cats, especially with MCT. Full article

Near-infrared (NIR) fluorescence lymphography-guided minimally invasive gastrectomy using indocyanine green (ICG) is employed to visualize draining lymphatic vessels and lymph nodes. Endoscopically injected ICG spreads along the gastric wall and emits fluorescence from the serosal surface of the stomach. We aimed to assess the efficacy of ICG diffusion in securing the resection margin. We retrospectively analyzed 503 patients with early gastric cancer located in the body of the stomach who underwent fluorescence lymphography-guided gastrectomy from 2018 to 2021. One day before surgery, ICG was endoscopically injected into four points of the submucosal layer peritumorally. We measured the extent of resection and the resection line based on the ICG diffusion area from the specimen using NIR imaging. The mean area of the ICG diffusion was 82.7 × 75.3 and 86.7 × 80.2 mm² on the mucosal and serosal sides, respectively. After subtotal gastrectomy, the length of the proximal resection margin was 38.1 ± 20.1, 33.4 ± 22.2, and 28.7 ± 17.2 mm in gastroduodenostomy, loop gastrojejunostomy, and Roux-en-Y gastrojejunostomy, respectively. The ICG diffusion area along the gastric wall secured a resection margin of >28 mm. The ICG diffusion range can be used as a simple and easy method for determining the resection margin during gastrectomy using NIR imaging. Full article

Since the introduction of indocyanine green (ICG) as a fluorophore in near-infrared imaging, fluorescence visualization has become an essential tool in many fields of surgery. In the field of gynecology, recent new applications have been proposed and found their place in clinical practice. Different applications in gynecology were investigated, subcategorized, and overviewed concerning surgical applications and available dyes. Specific applications in which fluorescence-guided surgery was implemented in gynecology are described in this manuscript—namely, sentinel node biopsy, mesometrium visualization, angiography of different organs, safety issues in pregnant women, ureters visualization, detection of peritoneal metastases, targeted fluorophores for cancer detection, fluorescent contamination hysterectomy, lymphography for lower limb lymphedema prevention, tumor margin detection, endometriosis, and metastases mapping. With evolving technology, further innovative research on the new applications of fluorescence visualization in cancer surgery may help to establish these techniques as standards of high-quality surgery in gynecology. However, more investigations are necessary in order to assess if these innovative tools can also be effective to improve patient outcomes and quality of life in different gynecologic malignancies. Full article

Identification of lymphatics by Indocyanine Green (ICG) lymphography in patients with severe lymphedema is limited due to the overlying dermal backflow. Nor can the method detect deep and/or small vessels. Multispectral optoacoustic tomography (MSOT), a real-time three- dimensional (3D) imaging modality which allows exact spatial identification of absorbers in tissue such as blood and injected dyes can overcome these hurdles. However, MSOT with a handheld probe has not been performed yet in lymphedema patients. We conducted a pilot study in 11 patients with primary and secondary lymphedema to test whether lymphatic vessels could be detected with a handheld MSOT device. In eight patients, we could not only identify lymphatics and veins but also visualize their position and contractility. Furthermore, deep lymphatic vessels not traceable by ICG lymphography and lymphatics covered by severe dermal backflow, could be clearly identified by MSOT. In three patients, two of which had advanced stage lymphedema, only veins but no lymphatic vessels could be identified. We found that MSOT can identify and image lymphatics and veins in real-time and beyond the limits of near-infrared technology during a single bedside examination. Given its easy use and high accuracy, the handheld MSOT device is a promising tool in lymphatic surgery. Full article