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This video demonstrates Fluorescence Angiography During Laparoscopic Sleeve Gastrectomy performed by Dr. R. K. Mishra at World Laparoscopy Hospital. A new technology involving indocyanine green (ICG) fluorescence angiography has been introduced to assess tissue perfusion and perform vascular mapping during laparoscopic surgery. The purpose of this video was to describe the use of this technology to identify the variable blood supply patterns to the stomach and gastroesophageal (GE) junction during laparoscopic sleeve gastrectomy (LSG), which may help in preserving the blood supply and preventing ischemia-related leaks.

Fluorescence imaging is currently being used for multiple applications across multiple subspecialties of surgery. Regarding gastrointestinal surgery, this technology can be used to assess proper tissue perfusion and vascular mapping of the patient's arterial/venous anatomy, as described in this article. Our group is currently exploring this technology in LSG cases to perform “perfusion-preserving” dissection and checking for adequate perfusion of the sleeve product afterward.

Laparoscopic Sleeve Gastrectomy (LSG) is one of the most commonly performed bariatric procedures worldwide, known for its effectiveness in weight loss and improvement of metabolic conditions like type 2 diabetes. Despite being relatively safe, LSG carries risks such as staple line leaks, which are rare but potentially serious complications. Ensuring adequate perfusion of the gastric sleeve is crucial for reducing such risks. Fluorescence angiography (FA) has emerged as a valuable intraoperative tool to assess gastric tissue perfusion in real-time, enhancing the safety of bariatric surgery.

What is Fluorescence Angiography?
Fluorescence angiography involves the use of indocyanine green (ICG) dye, a fluorescent contrast agent, which is injected intravenously. When illuminated with near-infrared (NIR) light, ICG emits fluorescence, allowing surgeons to visualize blood flow and tissue perfusion directly on the surgical monitor. This technique helps in assessing whether the stomach tissue along the staple line is receiving sufficient blood supply, a critical factor in preventing ischemia-related complications.

Application in Laparoscopic Sleeve Gastrectomy
During LSG, the surgeon creates a tubular gastric sleeve by resecting a large portion of the stomach. Staple line leaks can occur if areas of the sleeve are poorly perfused. FA can be performed intraoperatively to:

Identify poorly perfused areas along the staple line

Guide staple line reinforcement or trimming to ensure only well-perfused tissue remains

Reduce postoperative complications such as leaks and strictures

Procedure Overview

After completing the gastric sleeve, the patient receives an intravenous injection of ICG.

Using a near-infrared laparoscopic camera, the surgeon observes the fluorescence pattern along the staple line.

Areas showing delayed or inadequate fluorescence indicate poor perfusion. These regions may be reinforced with sutures or adjusted to prevent future complications.

The procedure is quick, usually adding only a few minutes to the overall surgery time.

Advantages of Fluorescence Angiography in LSG

Real-time perfusion assessment: Provides immediate visualization of blood supply

Reduction in complications: Helps prevent staple line leaks and tissue necrosis

Enhanced decision-making: Assists surgeons in tailoring interventions based on tissue perfusion

Minimally invasive: Fully compatible with laparoscopic techniques, adding minimal operative time

Limitations and Considerations

ICG is generally safe, but rare allergic reactions can occur.

Requires specialized near-infrared laparoscopic equipment.

Interpretation of fluorescence can be subjective; experience and training are essential.

Conclusion
Fluorescence angiography is a promising adjunct in laparoscopic sleeve gastrectomy, offering real-time insights into gastric perfusion and helping surgeons reduce the risk of serious complications. As bariatric surgery continues to evolve, FA represents a step forward in improving patient safety and surgical outcomes.