The future of minimally invasive surgery is increasingly connected with technologies that allow surgeons to see more than conventional white-light imaging can provide. Fluorescence-Guided Surgery (FGS) is one of these important developments, offering real-time visualization through near-infrared fluorescence and agents such as indocyanine green (ICG). At WALS 2025, Dr. Steven D. Wexner presented insights related to the consensus approach to fluorescence-guided surgery, discussing its clinical applications, standardization, and future role in advanced surgical practice.

Held during the 8th World Congress of Laparoscopic Surgeons at The Leela Ambience Gurugram, the session focused attention on a technology that is increasingly being integrated into laparoscopic, robotic, colorectal, oncologic, and other surgical procedures.

From White Light to Image-Guided Surgery

Traditional surgery depends heavily on the surgeon's understanding of anatomy, tissue appearance, tactile information, vascular landmarks, and operative experience. Fluorescence imaging adds another layer of information.

With ICG fluorescence, the surgeon can use near-infrared imaging to visualize fluorescence within tissues after administration of the dye. This can assist in assessing perfusion and identifying selected anatomical or lymphatic structures. International consensus research involving Dr. Wexner found agreement among experts from five continents on 41 of 44 statements concerning the general use of near-infrared fluorescence imaging and ICG-guided surgery.

The significance of this development is not simply that surgeons have another imaging mode. Rather, it represents a movement toward image-guided decision-making during surgery, where visual information can be obtained dynamically while the procedure is being performed.

Why Perfusion Assessment Matters

For colorectal surgeons, bowel perfusion is particularly important when constructing an anastomosis. An anastomosis requires adequate vascular supply for healing, and intraoperative assessment of the selected bowel segments is therefore an important component of surgical decision-making.

Fluorescence imaging can provide real-time information about perfusion and may help the surgeon assess whether the selected tissue demonstrates fluorescence before proceeding with reconstruction. The consensus literature specifically identifies fluorescence imaging as an important tool for tissue-perfusion evaluation.

At the same time, fluorescence should not be interpreted in isolation. Tissue appearance, anatomical factors, hemodynamic status, operative technique, and the surgeon's overall clinical judgment remain relevant.

Beyond Anastomotic Perfusion

The potential of fluorescence-guided surgery extends across multiple surgical applications. Published consensus findings describe roles for fluorescence imaging in:

Anatomical localization: Fluorescence can assist with identifying selected critical structures during difficult dissection.

Tumor visualization: Fluorescence-based techniques are being investigated and used in selected oncologic applications to improve visualization.

Sentinel lymph-node mapping: Fluorescence can help visualize lymphatic pathways and selected sentinel nodes.

Tissue perfusion: Near-infrared fluorescence provides additional information about blood supply.

Organ delineation: Fluorescence can assist with visualization of selected anatomical boundaries.

Parathyroid localization: Fluorescence imaging has also been investigated for identifying parathyroid glands.

These applications illustrate why fluorescence-guided surgery is not limited to a single specialty.

The Importance of ICG Protocols

One of the challenges in fluorescence-guided surgery is determining how the technology should be used consistently. The amount of ICG administered, concentration, route of administration, timing of injection, imaging equipment, and interpretation of fluorescence can all influence the information available during surgery.

The international modified Delphi consensus found strong agreement that further research is needed to determine the optimum dose, concentration, route, and timing of ICG administration.

This highlights an important principle in advanced surgical technology: adoption should be accompanied by education, standardized protocols where appropriate, and continued evaluation of clinical evidence.

Role in Robotic and Laparoscopic Surgery

Fluorescence imaging is particularly relevant to modern laparoscopic and robotic surgery because these platforms can integrate near-infrared imaging into the operative workflow.

During minimally invasive procedures, surgeons can alternate between conventional visualization and fluorescence imaging to obtain additional information when required. This may be useful during vascular assessment, tissue-perfusion evaluation, anatomical identification, and selected oncologic procedures.

For robotic and laparoscopic surgeons, therefore, knowledge of fluorescence technology is increasingly becoming part of the broader skill set associated with advanced image-guided surgery.

Training the Next Generation of Surgeons

Technology alone does not guarantee better surgical decision-making. Surgeons need to understand what fluorescence represents, when it should be used, how to interpret the displayed signal, and what limitations may affect its reliability.

Training programs can introduce surgeons to:

• Principles of near-infrared fluorescence
• ICG administration and safety considerations
• Fluorescence-based perfusion assessment
• Interpretation of fluorescence patterns
• Integration with laparoscopic and robotic systems
• Anatomical identification techniques
• Appropriate clinical indications
• Limitations and potential sources of misleading fluorescence
• Evidence-based use of image-guided technologies

Such training can help ensure that fluorescence imaging becomes a meaningful component of surgical practice rather than simply an additional technological feature.

Research and the Future of FGS

The consensus surrounding fluorescence-guided surgery also demonstrates that important questions remain open. Although experts broadly recognize the usefulness and safety of fluorescence imaging and ICG across multiple applications, optimization remains an active research area.

Future research may focus on quantitative rather than purely visual fluorescence assessment, improved imaging hardware, standardized interpretation criteria, new fluorescent agents, molecular imaging, artificial-intelligence-assisted analysis, and integration with robotic surgical systems.

Large multicenter studies will also remain important for determining which applications translate into measurable improvements in surgical outcomes.

Dr. Steven D. Wexner's Contribution to the Discussion

Dr. Steven D. Wexner's participation at WALS 2025 is significant within this broader development because his work has included colorectal surgery and fluorescence-guided applications. He was among the authors of the international modified Delphi consensus study on near-infrared fluorescence imaging and ICG-guided surgery, which brought together experts from multiple continents.

His WALS 2025 presentation connected this international consensus perspective with the practical challenges faced by surgeons adopting fluorescence-guided techniques.

The central educational message is that modern surgery is moving toward increasingly precise visualization while maintaining the fundamental importance of surgical anatomy, judgment, technique, and evidence-based practice.

A Valuable WALS 2025 Learning Session

The Consensus Statement on Fluorescence-Guided Surgery from Dr. Steven D. Wexner at WALS 2025 provides valuable educational content for surgeons interested in colorectal surgery, minimal access surgery, robotic surgery, image-guided procedures, and emerging surgical technologies.

The session demonstrates how fluorescence imaging can potentially enhance visualization during surgery while also emphasizing the importance of appropriate protocols, training, research, and clinical judgment. As minimally invasive and robotic surgery continue to evolve, technologies such as near-infrared fluorescence may become increasingly integrated into the operating room.

For surgeons and trainees, understanding both the capabilities and limitations of fluorescence-guided surgery is essential. The WALS 2025 discussion provides an opportunity to explore this rapidly developing field and understand how international consensus and clinical research can contribute to the responsible adoption of new surgical technologies.