Usefulness of indocyanine green fluorescence imaging to evaluate intestinal blood flow during laparoscopic surgery for strangulated small bowel obstruction: a report of two cases

Abstract

Introduction and importance: Strangulated small bowel obstruction (SBO) is an emergency condition in which intestinal necrosis can occur. However, it is sometimes difficult to precisely assess intestinal blood flow. In recent years, assessment of organ blood flow using indocyanine green fluorescence imaging (ICG-FI) has become increasingly common in laparoscopic surgery.

Case presentation: We report two cases of strangulated SBO in which intestinal blood flow was assessed using indocyanine green and treatment was achieved in a minimally invasive manner through a laparoscopic approach. Case 1: A 76-year-old man presented with abdominal pain and was diagnosed with strangulated SBO. We performed emergency laparoscopic surgery and dissected the loop of the band into which the intestine was strangulated. Although the procedure was converted to open surgery, we used ICG-FI to evaluate the intestinal blood flow and decided to preserve the intestines. Case 2: An 86-year-old woman presented with vomiting and was diagnosed with strangulated SBO by using abdominal computed tomography. Emergency laparoscopic surgery was performed, and strangulation was relieved under a pneumoperitoneum. The intestine was preserved because intestinal blood flow was observed on the ICG-FI.

Clinical discussion: In this report, we presented two cases of strangulated SBO in which laparoscopic surgery was initiated and ICG-FI was used intraoperatively. Traditionally, the decision to resect the bowel relies heavily on subjective findings, which can lead to unnecessary resections and postoperative complications. ICG-FI offers a more objective assessment of perfusion and has shown potential in various emergency and elective gastrointestinal procedures. Its intraoperative use can assist in real-time surgical decision-making, even in challenging cases with persistent discoloration after release of strangulation. Moreover, when laparoscopic access is feasible, this approach can enhance visualization, facilitate teamwork, and minimize invasiveness. While laparoscopy may not be appropriate in all cases, particularly in hemodynamically unstable patients or those with severe intestinal dilation, it remains a valuable strategy in selected patients, especially when combined with advanced tools such as ICG-FI.

Conclusion: In laparoscopic surgery for strangulated small bowel obstruction, ICG fluorescence imaging can be a valuable tool for assessing intestinal blood flow, which can reduce unnecessary resection of the intestine and enhance patient outcomes in elective cases.

Keywords: Indocyanine green; Laparoscopic surgery; Strangulated small bowel obstruction.