NIR/ICG fluorescence imaging with the KARL STORZ modular system solution
Using the fluorescent dye indocyanine green (ICG)* and light in the near infrared (NIR) range, KARL STORZ offers the NIR/ICG system for brilliant, laser-free FULL HD imaging of the vascular system, biliary tract, and lymphatic system. The NIR/ICG system is based on the IMAGE1 S camera platform.
- NEW: 5 mm telescope now available
- Multidisciplinary applications, for instance in general and visceral surgery, thoracic surgery, gynecology, urology, and reconstructive surgery
- Xenon-based technology (no laser protection required)
- Optimal illumination and contrast enhancement
- All-in-one solution for laparoscopic and open surgery (VITOM® II ICG)
- Outstanding user friendliness
*Please verify that the fluorescent dye indocyanine green is approved for the respective indication in your country.
Perfusion assessment plays an important role in various medical specialties. Ischemic areas can be easily identified by using the NIR/ICG system and administering ICG. This allows intraoperative action to be taken and reduces the duration of surgery.
- Rapid perfusion assessment of a planned resection zone as well as the subsequent anastomosis, including colonic anastomoses1, esophageal anastomoses, and gastric bypass anastomoses2
- Perfusion assessment in flap plasty
- Visualization of liver segments
1 Koh et al., Fluorescent Angiography Used to Evaluate the Perfusion Status of Anastomosis in Laparoscopic Anterior Resection, 2016
2 Boni et al., Clinical Applications of Indocyanine Green (ICG) Enhanced Fluorescence in Laparoscopic Surgery, 2015
Following intravenous administration, ICG naturally collects in the gallbladder and bile ducts. This allows the rapid and reliable identification of gallbladder and bile duct anatomy. Thanks to intuitive switching between white light and fluorescence imaging, cholecystectomy can be performed rapidly and more safely.
- Allows the reliable differentiation between the cystic duct and common bile duct3
- Intraoperative leaks displayed with ICG
- Shortened surgical duration with ICG compared to standard cholangiography4
3 Boni et al., Doctor-to-Doctor Manual ENDO-PRESS®, NIR/ICG Fluorescence Imaging in Laparoscopic Surgery (ISBN 978-3-89756-934-8)
4 Dip et al., Cost analysis and effectiveness comparing the routine use of intraoperative fluorescent cholangiography with fluoroscopic cholangiogram in patients undergoing laparoscopic cholecystectomy, 2014
*SPECTRA A: Not for sale in the U.S.
The visualization of the lymphatic system is very helpful in many medical specialties. With NIR/ICG imaging, the entire lymphatic system5 around the tumor can be displayed in real time without use of radioactivity6.
- Non-radioactive method for lymph node visualization
- Detection rates compare favorably with established methods of lymph node visualization7
- Multidisciplinary use, for instance in gynecology, urology, and general surgery
5 (S)LN by means of the intradermal administration of ICG is already approved in Italy (breast cancer), Japan and Russia. Please inform yourself in advance about the potential off-label use of ICG at your hospital and in your country.
6 Papadia et al., Doctor-to-Doctor Manual ENDO-PRESS®, ICG-Enhanced Fluorescence-Guided SLN Mapping in Gynecological Malignancies (ISBN 978-3-89756-932-4)
7 Imboden et al., A Comparison of Radiocolloid and Indocyanine Green Fluorescence Imaging, Sentinel Lymph Node Mapping in Patients with Cervical Cancer Undergoing Laparoscopic Surgery, 2015
The KARL STORZ – Near Infrared (NIR/ICG) System offers the possibility to assess if the perfusion of the colon is satisfactory. Laparoscopically, surgeons are naturally unable to control the anastomosis with palpation, but can control it visually, therefore NIR/ICG fluorescence angiography provides a real-time intraoperative solution.
NIR/ICG fluorescence angiography is quick and easy. To confirm blood supply is sufficient, the surgeon identifies the borders of the healthy bowel segment before setting the staple-line and immediately after completing the anastomosis. Well perfused tissue can be easily distinguished from ischemic areas by illumination of ICG after intravenous injection. Thereby, the surgeon can confirm the bowel resection borders are well perfused and if not can intervene immediately to re-set the anastomosis.
With more than 694,000 deaths worldwide in 2012 according to the WHO (World Health Organization), colorectal cancer is the third most common type of cancer. In most cases, radical surgery is the only way for total treatment.
Successful colorectal anastomosis is an important factor in the healing process of radical surgery. The perfusion of the anastomosed bowel segments is critical. The mean anastomotic leakage (AL) rate for colic and rectal anastomosis was 7.2%, whereas AL for rectal anastomosis alone was 8.8%1 resulting in a 6-22% mortality and 56% morbidity rate opposed to patients without AL after colorectal resection2.
KARL STORZ - Near Infrared (NIR/ICG) fluorescence angiography enables delineation of ischemic areas. According to a recent study the anastomotic leakage rate was reduced to 0% by using NIR/ICG imaging for the assessment of the perfusion during surgery3.
1. Pommergaard HC, et al. Colorectal Dis. 2014.
2. Daams F, et al. World J Gastroenterol. 2013.
3. Boni L, et al. Surg. Endos. 2015.
The KARL STORZ Near Infrared (NIR/ICG) system and the marker indocyanine green (ICG) enables non-radioactive visualization of the entire lymph system surrounding a tumor in real time.
The system offers the following advantages:
- Non-radioactive lymph node detection method
- Multidisciplinary use
- Xenon-based technology (no laser safety measures necessary)
- Intuitive switchover between the standard white light and the fluorescence mode via footswitch
- Physicians describe their surgical experience with the system as follows:
The NIR/ICG system allows the reduction of radical lymphadenectomy and, at the same time, visual control makes the en-bloc resection of lymph nodes easier.
*The intradermal administration of indocyanine green for (S)LN has already been approved in Italy (breast cancer), Japan and Russia. Please inform yourself in advance about the potential for the off-label use of ICG in your hospital / country.
In gynecology, the degree of tumor involvement in the sentinel lymph node (SLN) is of great importance as it provides medical information about the tumor stage and is thus one of the main prognostic factors. In breast cancer surgery, SLN detection with the radioactive tracer 99mTc is the gold standard. In other areas of gynecological tumor surgery, its benefits in comparison to elective lymph node dissection is the subject of discussion. As a new, non-radioactive imaging technique, NIR imaging with ICG can provide a useful contribution to this field.1 SLN mapping of endometrial carcinoma yielded the following results (radioactive tracer 99mTc vs. ICG):
|Radioaktiver Tracer 99mTc||ICG|
Total SLN detection rate
|Study 12||83 %||61 %||95,5 %||95,5 %|
1Papadia et al., Silver Books, NIR/ICG-Enhanced Fluorescence-Guided Imaging of Malignant Tumors in Gynecology (ISBN 978-3-89756-931-7)
2 Imboden et al., Surg. Oncol. 2015
Fluorescence-guided visualization of the lymphatic system with the NIR/ICG system from KARL STORZ is now used in many other disciplines. The following examples have already been described in the literature:
- Prostate carcinoma
- Penile carcinoma
General Surgery 3,4:
- Colorectal carcinoma
- Pancreatic carcinoma
- Gastric carcinoma
1 Jeschke et al. 2012
2 Hruby et al. 2015
3 Boni et al. 2014
4 Boni et al., Doctor-to-Doctor Manual ENDO-PRESS®, ICG-enhanced Fluorescence-guided Laparoscopic Surgery (ISBN 978-3-89756-934-8)
The VITOM® II ICG from KARL STORZ also offers an optimal solution for visualizing the lymph system in open surgery. VITOM® II ICG can be used with the NIR/ICG system.
- Also allows fluorescence-supported lymph node detection in open surgery in various disciplines such as, for example, gynecology in the case of breast cancer
- Possibility for the integration of an exoscope by means of a holding arm in the surgeon’s space
- For optimal results, the SPECTRA A* visualization mode can also be activated to achieve contrast enhancement
* SPECTRA A: Not for sale in the U.S.
Illumination with near infrared light using indocyanine green (ICG) enables enhanced visualization of anatomical structures such as the biliary ducts, the lymphatic system and blood vessels. Use of the IMAGE1 S NIR system proves to be a versatile application in liver surgery. It allows the diagnosis of potential liver metastases, primary liver tumors or bile leakage and makes it possible to perform fluorescence-assisted liver segmentectomy.
The system offers the following advantages:
- Multidisciplinary use in both endoscopy and open surgery
- Laparoscopes with a diameter of 10 mm and now available with a diameter of 5 mm
- Xenon-based technology (no laser safety measures necessary)
- Intuitive switchover between standard white light and fluorescence mode via footswitch
Primary liver cancer is the sixth most common cancer worldwide. Liver metastases are even 20 times more common than primary liver tumors.1 The NIR/ICG system offers the following advantages for liver surgery:
- ICG in conjunction with near infrared light allows the intraoperative visualization of metastases and carcinoma of the liver above or below the tissue surface2
- Possible to diagnose small metastases with millimeter accuracy3
- Easier to determine the extent of resection4
1 Krebsraten in Deutschland 2011/2012 (10.), Robert-Koch-Institut, Berlin
2 Within accuracy of 1 mm depending on the tissue composition
3 Tummers et al., First experience on laparoscopic near-infrared fluorescence imaging of hepatic uveal melanoma metastases using indocyanine green, 2014
4 Boni et al., Doctor-to-Doctor Manual ENDO-PRESS®, NIR/ICG Fluorescence Imaging in Laparoscopic Surgery (ISBN 978-3-89756-934-8)
A further possible application in liver surgery is the selective administration of ICG into the supply vessel in order to aid laparoscopic and open liver segmentectomy. Partial liver resection requires a sound knowledge of the existing course of the vessel and the boundaries of the individual segments as well as the diverse anatomical features of the blood vessels:
- The tumor is localized intraoperatively aided by CT, MRI and ultrasound techniques
- ICG is injected into the supply vessel of the segment
- Fluorescence allows easy differentiation of the affected segment from the adjacent non-fluorescing segments
ICG fluorescence can also help to detect bile leakage following liver segmentectomy or liver transplantation procedures.
The VITOM® II ICG system from KARL STORZ offers an optimal solution for open liver surgery. VITOM® II ICG can easily be used with the IMAGE1 S NIR system in laparoscopy.
- Enables both open surgical and fluorescence-assisted diagnosis of liver metastases and liver carcinoma as well as the visualization of liver segments and bile leakage
- Possible to integrate VITOM® into the surgeon’s operating field by means of a holding arm
- For optimal fluorescence results, the SPECTRA A visualization mode can also be activated. This results in a color shift in the image
Photodynamic diagnostics (PDD)
Features that are invisible under regular light can be visualized with blue light using specially modified endoscopes.
Photodynamic diagnostics (PDD) allows visually differentiating malignant changes from healthy tissue at an early stage. For this purpose, light of a special spectral range is guided into the body through a nearly loss-free optical fiber system.
The D-LIGHT C light source is a key element of the PDD unit. After instilling a tumor marker substance, malignant tissue can be differentiated from benign tissue in the fluorescence mode: cancerous areas in the bladder fluoresce red when exposed to the stimulation light from the D-LIGHT C system. This facilitates the detection of flat neoplastic lesions such as dysplasias and carcinoma in situ, which can be concealed by normal or unspecifically inflamed mucus membranes, as well as small papillary tumors. White light alone does not achieve such differentiation, and consequently such early findings may be overlooked.
KARL STORZ started selling the first system for photodynamic diagnostics as early as 1995. Systems consist of precisely harmonized components: the high performance light source D-LIGHT C, special telescopes, and a particularly light-sensitive endoscopy camera. PDD relies on suitable and approved marker substances.
- Excellent image quality in both examination modes – thanks to modern CCD video chip technology and integrated auto-focus function
- Optimal gliding movement of the distal tip that responds exactly to controls – thanks to the robust design of the insertion sheath using high-quality materials
- Accurate and user-friendly work during an intervention – thanks to the ergonomic handle design and the particularly light overall weight
- Rapid changeover between white light and autofluorescence modes – thanks to convenient activation of the function keys
Autofluorescence (AF) can differentiate even early malignant changes from benign tissue. The autofluorescence technique is based on the fact that some substances in the submucosa fluoresce when exposed to light of a certain wavelength. Pathological findings are visible as dark areas against an apple-green background (normal tissue).
Features that are invisible under regular light can be visualized with blue light using specially modified endoscopes. For this purpose, light of a special spectral range is guided into the body through a nearly loss-free optical fiber system. The system's major advantage is the fact that it does not require marker substances. One of its applications is the early diagnosis of bronchial cancer.
The D-LIGHT C/AF light source is a key element of the KARL STORZ AF unit. In the fluorescence mode, malignant and benign tissue can be differentiated.
AF is used in ENT, bronchoscopy, laparoscopy, and for gynecological indications.