Table 6 Summary of the advantages, disadvantages, contraindications, limitations, and cost-effectiveness of Indocyanine Green (ICG) implementation in emergency and trauma surgery

Advantages

Real-Time Assessment: Provides immediate visualization of tissue perfusion, enabling quicker and more accurate decision-making

Enhanced Visualization: Improves clarity of critical structures (e.g., blood vessels, bile ducts) in complex anatomical situations, reducing the risk of surgical errors

Minimally Invasive: Compatible with laparoscopic and robotic surgery, leading to faster recovery times and fewer complications compared to open surgery

Low Risk of Allergic Reactions: Generally safe with a low incidence of allergic reactions, making it suitable for a wide range of patients

No Ionizing Radiation: Safer for patients and surgical staff as it avoids the risks associated with ionizing radiation, especially in cases requiring multiple imaging sessions

Disadvantages

Limited Tissue Penetration: Effective only for shallow tissues, limiting its use in assessing deeper structures or organs

Short Imaging Window: Requires precise timing for imaging, which can be challenging in emergency settings

Need for Specialized Equipment: Requires access to near-infrared cameras and other specialized tools, which may not be available in all surgical settings

Operator Dependence: The effectiveness of ICG is highly dependent on the operator’s experience and skill, which can lead to variability in results

Absolute Contraindications

Allergy to Iodine or ICG: Patients with known allergies to iodine or ICG should not be administered this dye due to the risk of severe allergic reactions

Relative Contraindications

Liver Dysfunction: Patients with significant liver impairment may have altered clearance of ICG, affecting fluorescence results

Renal Impairment: Although ICG is not primarily excreted by the kidneys, caution is advised in patients with severe renal dysfunction

Pregnancy and Breastfeeding: While not strictly contraindicated, there is limited data on the safety of ICG in pregnant or breastfeeding women, warranting caution

Limitations

Limited Penetration Depth: ICG fluorescence is less effective for evaluating perfusion in large or deep structures, which may be critical in some surgical cases

Cost and Accessibility: High cost of ICG dye and necessary imaging equipment may limit its use, especially in resource-limited settings or low-volume centers

Risk of Misinterpretation: Variability in tissue perfusion, timing, and equipment settings can lead to potential misinterpretation, affecting surgical decisions

Cost-Effectiveness

Initial Cost: The expense of ICG and specialized equipment can be high, but this may be offset by improved outcomes and reduced complication rates in high-volume centers

Long-Term Savings: Potential for reduced surgical complications, shorter operative times, and quicker recovery could translate to overall cost savings in the long term

Resource-Limited Settings: In settings with limited resources, the high cost of implementation may not be justified if the technology is underutilized or alternatives are available