Fluorescence in laparoscopic appendectomy stump closure: a possible new imaging technique in emergency settings

Introduction: Explore a new possible application of emergency indocyanine green (ICG): this possible emerging use of ICG investigates whether fluorescence angiography for laparoscopic appendectomy (LA) may reduce post-operative hospitalization and intra-abdominal abscesses (IAA) thanks to the evaluation of appendiceal stump vascularization and, consequently, the identification of the exact site of appendiceal transection and the best technique to perform this maneuver in order to help surgeons to identify which kind patients, if any, would benefit from its use. The primary end point is the duration of post-operative hospital stay. Secondary end points are the rate of IAA, the operative time (OT) and the 30-days overall complications. Methods: We performed 50 LA: all patients, during the procedure, underwent ICGFA, following a specific intraoperative protocol, to evaluate the appendiceal stump perfusion and the exact site of transection. All patients were categorized. Results: We analyzed the mean operative time, the technique of transection of the appendiceal base, the different grades of acute appendicitis, the hospital stay and the definitive histological examination. All patients underwent clinical follow-up for the following 30 days. Our experiment could suggest that ICG-FA could be one of the decision-making modalities for patients with complicated acute appendicitis to manage the appendicular base and stump with the different devices, reducing the use of endostaplers in well-selected patients Conclusions: From our first experience we have observed how ICG-FA during LA is a feasible method that could improve the postoperative outcomes. Stronger evidencebased studies, such as randomized trials, will be needed to demonstrate its efficacy as well as a future quantification analysis of ICG-FA, thanks to specific software solutions, will be essential in the widespread search for reliable quantification of perfusion. We are aware that our experiment has many limitations, such as the limited number of patients involved and the absence of standardization, but ICG fluorescence could be a useful method to assess stump vascularization, guide the following surgical strategy, and eventually reduce postoperative complications. Larger, further randomized prospective trials are needed to standardize, test, and eventually validate this new technique.