Clinical practice of indocyanine green fluorescence imaging in robotic liver surgery - a global expert survey

Noa L E Aegerter; Christoph Kuemmerli; Adrian T Billeter; Caroline Berchtold; Felix Nickel; Cristiano Guidetti; Taiga Wakabayashi; Iswanto Sucandy; Brian K Goh; Mathieu D'Hondt; Hugo Pinto Marques; Janina Eden; Philipp Dutkowski; Jason Hawksworth; Patrick Starlinger; Beat P Müller; Philip C Müller; Robotic Liver Surgery Expert Group

doi:10.1007/s00464-025-12553-z

Clinical practice of indocyanine green fluorescence imaging in robotic liver surgery - a global expert survey

Surg Endosc. 2026 Feb 9. doi: 10.1007/s00464-025-12553-z. Online ahead of print.

Authors

Noa L E Aegerter^{1

2}, Christoph Kuemmerli¹, Adrian T Billeter¹, Caroline Berchtold¹, Felix Nickel³, Cristiano Guidetti⁴, Taiga Wakabayashi⁵, Iswanto Sucandy⁶, Brian K Goh^{7

8}, Mathieu D'Hondt⁹, Hugo Pinto Marques¹⁰, Janina Eden¹, Philipp Dutkowski¹, Jason Hawksworth¹¹, Patrick Starlinger¹², Beat P Müller¹, Philip C Müller¹³; Robotic Liver Surgery Expert Group

Collaborators

Robotic Liver Surgery Expert Group:
Yuta Abe, Jawad Ahmad, Adnan Alseidi, Koij Asai, Horacio Asbun, Fabrizio Di Benedetto, Ielpo Benedetto, Emrullah Birgin, Ugo Boggi, Ruth Bustamante, Tan To Cheung, Hop Tran Cao, Yee Lee Cheah, Roland Croner, Zoltan Czigany, Nroiyuki Egawa, Alessandro Ferrero, David Fuks, Daisuke Fukumori, Stefan Gilg, Jeroen Hagendoorn, Shinya Hayami, Asmus Heumann, Takao Ide, Taku Iida, Osamu Itano, Jan Philipp Jonas, Yutaro Kato, Felix Krenzien, Philipp Kron, Yoshikuni Kawaguchi, Mickael Lesurtel, Charles Chung-Wei Lin, John B Martinie, Takuya Minagawa, Zenichi Morise, Yutaka Nakano, Yusuke Nie, Atsushi Oba, Fabrizio Panaro, Florian Primavesi, Nuh Rahbari, Francesca Ratti, Christoph Reissfelder, Ricardo Robles-Campos, Andrea Ruzzenente, Olivier Saint-Marc, Moritz Schmelzle, Daniel Seehofer, Jimin Son, Gregor Stavrou, Stefan Stättner, Benjamin Struecker, Rutger-Jan Swijnenburg, Yu Takahashi, Samer Tohme, Christian Toso, Roberto Ivan Troisi, Stéphanie Truant, Christoph Tschuor, Roeland F de Wilde

Affiliations

¹ Clarunis, University Digestive Health Care Centre Basel, 4002 Basel, Basel, Switzerland.
² Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
³ Klinik Und Poliklinik Für Allgemein-, Viszeral- Und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland.
⁴ Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy.
⁵ Department of Surgery, Keio University School of Medicine, Tokyo, Japan.
⁶ Advent Health Medical Group, Digestive Health Institute at Florida Hospital Tampa/Minimally Invasive and Robotic Surgery, Tampa, FL, USA.
⁷ Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Center Singapore, Singapore, Singapore.
⁸ Surgery Academic Clinical Programme, Duke-National University of Singapore Medical School, Singapore, Singapore.
⁹ Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium.
¹⁰ Hepato-Biliary-Pancreatic and Transplantation Centre, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal.
¹¹ Department of Surgery, Abdominal Organ Transplantation Division, Columbia University Irving Medical Center, New York, NY, USA.
¹² Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
¹³ Clarunis, University Digestive Health Care Centre Basel, 4002 Basel, Basel, Switzerland. philip.mueller@clarunis.ch.

PMID: 41663748
DOI: 10.1007/s00464-025-12553-z

Abstract

Background: Indocyanine green (ICG) fluorescence imaging is increasingly incorporated into robotic liver resections (RLR), yet clinical practice regarding timing, dosage, and staining techniques is divergent. This international expert survey aimed to characterize current practices for ICG in RLR.

Methods: Experts in RLR were invited to participate based on surgical volume (experience of $\geq$ 50 RLR and $\geq$ 30 annual RLR). A 74-item questionnaire was developed following a literature search and reviewed by a steering committee. The survey addressed indications, timing, dosage, imaging technology, benefits, limitations, training, and future directions of ICG use. Responses collected between September and October 2025 were analyzed.

Results: Seventy experts from 19 countries completed the survey, corresponding to an 88% response rate. Centers performed a median of 180 annual liver resections, including 55 RLR. Most experts used ICG (96%) during RLR. Anatomical demarcation (91%), tumor localization (60%), and biliary anatomy assessment (60%) were the most frequent indications. 60% of experts use preoperative ICG, while intraoperative ICG is mainly administered for demarcation (67%) and biliary tract visualization (40%). Considerable heterogeneity exists in dosage, timing, and staining techniques, particularly in cirrhotic livers and for tumor localization. 53% of the experts had standard operating procedures, whereas 64% expressed the need for a higher degree of standardization. Reported benefits of ICG use included improved anatomical orientation, margin assessment, lesion detection, and support during complex resections. Perceived limitations included background fluorescence, tissue penetration and variable staining in diseased parenchyma. 80% anticipated improved outcomes with combined ICG and three-dimensional image-guidance.

Conclusion: ICG fluorescence is widely used in RLR and is an important cornerstone for precision-guided robotic liver surgery. Standardized clinical practice guidelines, structured training, and technological improvements in imaging and navigation systems are claimed to optimize its clinical use.

Keywords: Firefly; Indocyanine green; Liver resection; Robotic liver surgery.