Artificial intelligence applied to laparoscopic cholecystectomy: what is the next step? A narrative review.

Artificial Intelligence (AI) is playing an increasing role in several fields of medicine. AI is also used during laparoscopic cholecystectomy (LC) surgeries. In the literature, there is no review that groups together the various fields of application of AI applied to LC. The aim of this review is to describe the use of AI in these contexts. We performed a narrative literature review by searching PubMed, Web of Science, Scopus and Embase for all studies on AI applied to LC, published from January 01, 2010, to December 30, 2023. Our focus was on randomized controlled trials (RCTs), meta-analysis, systematic reviews, and observational studies, dealing with large cohorts of patients. We then gathered further relevant studies from the reference list of the selected publications. Based on the studies reviewed, it emerges that AI could strongly improve surgical efficiency and accuracy during LC. Future prospects include speeding up, implementing, and improving the automaticity with which AI recognizes, differentiates and classifies the phases of the surgical intervention and the anatomic structures that are safe and those at risk.

Robotic 8-mm trocar fascial wounds: To close or not to close?

BACKGROUND: The aim of this study was to investigate 8-mm robotic trocar site hernia (TSH) rate over the short and long term, providing aids to manage the related fascial wounds. METHODS: A retrospective analysis of 320 patients undergoing robotic surgery was conducted. The primary outcome was 8-mm TSH rate with a minimum follow-up of 12 months. The secondary outcome was the rate of haematomas and infections related to 8-mm wounds and their association with patient comorbidities and trocar position. RESULTS: One case of TSH was observed (0.31%). There were 15 cases of wound infection (4.68%) and 22 cases of wound haematoma (6.87%). Trocar related complications were significantly associated with patient comorbidities, not with trocar position. CONCLUSIONS: Our results do not justify the 8-mm fascial wound closure. Data concerning the association between trocar-related complications and patient comorbidities strengthen the need to implement the control of metabolic state and correct administration of perioperative therapy in high-risk patients.

Is proctoscopy sufficient for the evaluation of colorectal anastomosis prior to ileostomy reversal? A nationwide retrospective analysis of the Italian Society of Surgical Oncology Colorectal Cancer Network Collaborative group (SICO-CCN).

AIM: Several methods for assessing anastomotic integrity have been proposed, but the best is yet to be defined. The aim of this study was to compare the different methods to assess the integrity of colorectal anastomosis prior to ileostomy reversal. METHOD: A retrospective cohort analysis on patients between 1 January 2010 and 31 December 2020 with a defunctioning stoma for middle and low rectal anterior resection was performed. A propensity score matching comparison between patients who underwent proctoscopy alone and patients who underwent proctoscopy plus any other preoperative method to assess the integrity of colorectal anastomosis prior to ileostomy reversal (transanal water-soluble contrast enema via conventional radiology, transanal water-soluble contrast enema via CT, and magnetic resonance) was performed. RESULTS: The analysis involved 1045 patients from 26 Italian referral colorectal centres. The comparison between proctoscopy alone versus proctoscopy plus any other preoperative tool showed no significant differences in terms of stenoses (p = 0.217) or leakages (p = 0.103) prior to ileostomy reversal, as well as no differences in terms of misdiagnosed stenoses (p = 0.302) or leakages (p = 0.509). Interestingly, in the group that underwent proctoscopy and transanal water-soluble contrast enema the comparison between the two procedures demonstrated no significant differences in detecting stenoses (2 vs. 0, p = 0.98), while there was a significant difference in detecting leakages in favour of transanal water-soluble contrast enema via CT (3 vs. 12, p = 0.03). CONCLUSIONS: We can confirm that proctoscopy alone should be considered sufficient prior to ileostomy reversal. However, in cases in which the results of proctoscopy are not completely clear or the surgeon remains suspicious of an anastomotic leakage, transanal water-soluble contrast enema via CT could guarantee its detection.

Abdominal Wall Hernias-State of the Art of Laparoscopic versus Robotic Surgery.

Abdominal wall hernia repair, a common surgical procedure, includes various techniques to minimize postoperative complications and enhance outcomes. This review focuses on the comparison between laparoscopic and robotic approaches in treating inguinal and ventral hernias, presenting the ongoing situation of this topic. A systematic search identified relevant studies comparing laparoscopic and robotic approaches for inguinal and ventral hernias. Randomized control trials, retrospective, and prospective studies published after 1 January 2000, were included. Search terms such as hernia, inguinal, ventral, laparoscopy, robotic, and surgery were used. A total of 23 articles were included for analysis. Results indicated similar short-term outcomes for robotic and laparoscopic techniques in inguinal hernia repair, with robotic groups experiencing less postoperative pain. However, longer operative times and higher costs were associated with robotic repair. Robotic ventral hernia repair demonstrated potential benefits, including shorter hospital stay, lower recurrence and lower reoperation rates. While robotic surgery offers advantages such as shorter hospital stays, faster recovery, and less postoperative pain, challenges including costs and training requirements need consideration. The choice between laparoscopic and robotic approaches for abdominal wall hernias should be tailored based on individual surgeon expertise and resource availability, emphasizing a balanced evaluation of benefits and challenges.

Laparoscopic Heller-Dor myotomy in elderly achalasia patients: a single center experience with PSM analysis.

INTRODUCTION: Achalasia is a rare esophageal motility disorder of unknown etiology. With the ageing of the general population, treatment in elderly patients has become increasingly common; however, the gold standard treatment in this population remains unclear. The aim of this study was to evaluate the outcomes of laparoscopic Heller-Dor myotomy (LHM) in geriatric patients. MATERIAL AND METHODS: In this study, consecutive achalasia patients undergoing LHM at the University Hospital 'Federico II' of Naples from November 2018 to November 2022 were prospectively enrolled. Patients were divided into two groups based on their age at intervention: elderly (≥70 years) and younger (<70 years). The two study groups were compared by minimizing the different distribution of covariates through a propensity score matching analysis (PSM). RESULTS: In both populations, there was a significant improvement in terms of manometric parameters and symptoms after surgery. After applying one-on-one PSM, we obtained a total population of 48 achalasia patients divided into two groups (24 patients each). No significant differences were found in terms of demographic characteristics as well as preoperative and intraoperative variables between two groups. At 12 months from surgery, integrated relaxation pressure (IRP) was significantly lower in patients ≥ 70 years (p = 0.032), while younger patients scored significantly less at the post-operative Eckardt score (p = 0.047). CONCLUSIONS: Laparoscopic Heller-Dor myotomy is a safe and effective treatment even in elderly patients with rapid post-operative recovery, improvement of symptoms and manometric parameters.

Comment on Wijnia, J.W. A Clinician's View of Wernicke-Korsakoff Syndrome. J. Clin. Med. 2022, 11, 6755.

We have read with great interest the article by Wijnia [...].

Dual docking technique for robotic repair of simultaneous inguinal and umbilical hernia: A preliminary single center experience.

BACKGROUND: This study aimed to assess clinical results in terms of intraoperative outcomes, recovery and recurrence of our robotic technique for the treatment of patients affected by simultaneous inguinal and umbilical hernia, providing technical details to facilitate multiquadrant surgery in robotic hernia repair. METHODS: Data from patients affected by simultaneous primary inguinal and umbilical hernia who underwent robotic repair with our dual docking technique was retrospectively analysed. RESULTS: Fifteen patients were included. No intraoperative complications occurred. All patients achieved complete mobilisation within 7 h. The mean length of hospital stay was 21.6 h, with five patients discharged on the same day of surgery. There was no major complication and no recurrence within the median follow-up period of 673 days. CONCLUSIONS: This surgical technique shows optimal postoperative outcomes, such as early mobilisation and short length of stay. Our study provides an aid to surgeons performing multiquadrant robotic surgery for the treatment of abdominal hernias.

Cyanoacrylate in Colorectal Surgery: Is It Safe?

Anastomotic leakage (AL) of a gastrointestinal (GI) anastomosis continues to be an important complication in GI surgery. Since its introduction more than 60 years ago, Cyanoacrylate (CA) has gained popularity in colorectal surgery to provide "prophylaxis" against AL. However, although in surgical practice it is increasingly used, evidence on humans is still lacking. The aim of this study is to analyze in humans the safety of CA to seal colorectal anastomosis. All consecutive patients from Jannuary 2022 through December 2022 who underwent minimally invasive colorectal surgery were retrospectively analyzed from a prospectively maintained database. Inclusion criteria were a histological diagnosis of cancer, a totally minimally invasive procedure, and the absence of intraoperative complications. 103 patients were included in the study; N-butyl cyanoacrylate with metacryloxisulfolane (Glubran 2®) was used to seal colorectal anastomosis, no adverse reactions to CA or postoperative complications related to inflammation and adhesions occurred; and only one case of AL (0.9%) was recorded. We can consider this study an important proof of concept on the safety of CA to seal colorectal anastomosis. It opens the possibility of starting prospective and comparative studies in humans to evaluate the effectiveness of CA in preventing colorectal AL.

Could atmospheric temperature impact on adequate colon cleansing for colonoscopy? An observational, single-institution study.

PURPOSE: Several risk factors affecting the adequacy of colon cleansing have been proposed during the last decades. However, less is known about the impact that atmospheric aspects could have on adequacy of the bowel cleansing. The study aimed to investigate if the atmospheric temperature could impact on the bowel cleansing during colonoscopy. METHODS: A prospective maintained database of the colonoscopies performed since 1st August 2017 to 31st March 2020 was retrospective reviewed. The primary outcome of the study was to identify if the atmospheric temperature was associated with inadequate colon cleansing during colonoscopy. Secondary outcome was to identify the other factors associated with an inadequate colon cleansing. RESULTS: One thousand two hundred twenty patients were enrolled. High atmospheric temperature (> 25 °C) significantly influenced the colon cleansing (p < 0.0001). Adequate colon cleansing was negatively influenced by gender (female patients were associated with higher colon cleansing rate, p = 0.013), diabetes (p < 0.0001), previous pelvic surgery (p = 0.001), use of Beta-Blocker (p = 0.001), anti-platelet (p = 0.017), angiotensin converting enzyme inhibitors (p = 0.001), the adoption of 4 L Poly Ethylene Glycol solution (p = 0.009), single-dose regimen (p < 0.0001) low patients' compliance (p < 0.0001), higher age and body mass index (p < 0.0001 and p = 0.025), lower education levels (p < 0.0001). On the contrary, admission to the ward to perform bowel preparation positively impacted on colon cleansing (p = 0.002). CONCLUSION: Atmospheric temperature could play an important role in the colon cleansing during colonoscopy, being high temperature (> 25 °C) associated with lower rate of adequate bowel cleansing. However, being this relationship never studied before, these results must be confirmed by other studies.

Robotic Surgery and Functional Esophageal Disorders: A Systematic Review and Meta-Analysis.

The functional disease of the esophago-gastric junction (EGJ) is one of the most common health problems. It often happens that patients suffering from GERD need surgical management. The laparoscopic fundoplication has been considered the gold standard surgical treatment for functional diseases of the EGJ. The aim of our meta-analysis is to investigate functional outcomes after robotic fundoplication compared with conventional laparoscopic fundoplication. A prospective search of online databases was performed by two independent reviewers using the search string "robotic and laparoscopic fundoplication", including all the articles from 1996 to December 2021. The risk of bias within each study was assessed with the Cochrane ROBINS-I and RoB 2.0 tools. Statistical analysis was performed using Review Manager version 5.4. In addition, sixteen studies were included in the final analysis, involving only four RCTs. The primary endpoints were functional outcomes after laparoscopic (LF) and robotic fundoplication (RF). No significant differences between the two groups were found in 30-day readmission rates (p = 0.73), persistence of symptomatology at follow-up (p = 0.60), recurrence (p = 0.36), and reoperation (p = 0.81). The laparoscopic fundoplication represents the gold standard treatment for the functional disease of the EGJ. According to our results, the robotic approach seems to be safe and feasible as well. Further randomized controlled studies are required to better evaluate the advantages of robotic fundoplication.

EUS-guided endoscopic internal drainage with lumen-apposing metal stent for symptomatic hepatic cysts: a case series (with video).

Background and study aims Simple hepatic cysts (SHCs) are usually asymptomatic and detected incidentally. However, larger cysts may present with clinical signs and require treatment such as percutaneous aspiration or surgery with non negligeable rate of recurrence. We report a series of 13 consecutive patients who underwent EUS-guided lumen-apposing metal stent (LAMS) drainage of SHCs of the right and left liver. Patients and methods Nine men and four women, average age 71.9 years, underwent EUS-guided LAMS cyst drainage because of significant symptoms. At 1 month, LAMS was exchanged for a double pigtail stent (DPS), which was left in place for 3 months. Nine of the SHCs were located in the right liver and four in the left. The average diameter was 22.2 cm. Results Thirteen LAMS were successful delivered in all patients. However only 12 of 13 (92.3 %) remained in place. In one case, the LAMS slipped out immediately and was promptly removed and the cyst treated percutaneously. One of 12 patients experienced bleeding, which was treated conservatively. In seven patients, the LAMS was exchanged for a DPS; in the other five, it was successfully left in place until the patients died, given their comorbidities. At 10.5 months of follow-up, none of the SHCs had recurred. Conclusions EUS-guided LAMS drainage permits treatment of symptomatic SHCs without recurrence and with few adverse events. Comparative studies are needed to consider this approach as first intention.

Re-thoracoscopy for the management of gastric conduit dehiscence after minimally invasive McKeown esophagectomy.

INTRODUCTION AND IMPORTANCE: Gastric conduit dehiscence after esophagectomy represents a severe complication associated with high mortality. Surgical management is achieved through thoracotomy, but often ends up in conduit sacrifice and diversion. CASE PRESENTATION: A 59-years-old man underwent minimally invasive McKeown esophagectomy for esophageal adenocarcinoma. After a worsening of the postoperative course and evidence at the CT scan and endoscopy of highly suspect gastric conduit failure, the patient underwent an exploratory thoracoscopy, which revealed a partial dehiscence of the gastric conduit treated with resection of the dehiscent gastric wall by a linear stapler on the guide of a 36-french orogastric tube. Patient had a regular postoperative course without any complications and was discharged on the 6th postoperative day. CLINICAL DISCUSSION: The management of conduit necrosis is extremely challenging. There are several interventional options and it is difficult to decide the most appropriate treatment for each individual patient. In our case we decided to perform a reintervention with a thoracoscopic approach, resecting the dehiscent area of the gastric conduit. CONCLUSIONS: Minimally invasive surgery is a valid option for the management of post-operative complications, including those in emergency setting. Re-suturing a partial dehiscence of gastric conduit may be feasible if tissue conditions allow.

Endoscopic sinusectomy: 'a rose by any other name'. A systematic review of different endoscopic procedures to treat pilonidal disease.

AIM: Pilonidal sinus or Pilonidal Disease (PD) is a relatively common, benign but challenging condition. Although commonly encountered in practice, its ideal treatment is controversial. One of the most validated treatments is video-assisted surgery. In this context, very similar endoscopic techniques have been published under different names. The aim of this systematic review is to assess the differences among these proposed techniques and their outcomes. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed during all stages of this systematic review. A systematic search of the English literature was performed on multiple databases from 1 January 2014 to 3 April 2022. The primary outcome measure was the IDEAL framework stage of innovation. The key secondary outcome measures were the adherence to the IDEAL reporting guidelines, the Blencowe framework and the core outcome set (COS) for studies evaluating the introduction and evaluation of novel surgical techniques, the qualitative assessment using appropriate tools, the procedural variations and outcomes of each technique. RESULTS: A total of 38 articles were included reporting a very similar technique under eight different acronyms. The number of patients varied from 9 to 250. Mean follow-up ranged from 1 to 60 months. There was only one published study of IDEAL 3. The majority (58%) were IDEAL 2a studies. Reporting of domains in the IDEAL reporting guidelines and Blencowe framework was poor, with most studies not reporting the component steps of procedures or efforts to standardize them. Half of COS domains were markedly underreported. The quality of the evidence was categorized as having a risk of bias from moderate to critical level in all nine comparative non-randomized series. Postoperative complications occurred in 0%-6% of cases, including surgical site infection, poor or failed wound healing bleeding, granuloma, haematoma, and pain requiring intervention. The recurrence rate varied from 0% to 22%. CONCLUSION: The study demonstrates that reporting on technical aspects of interventions for PD is poor, thus warranting a better-quality control of surgical techniques. It is advisable to group all endoscopic procedures under the umbrella term of 'endoscopic sinusectomy', thus embracing the two main principles of this technique, that is, video assistance and PD ablation.

Endoscopic approach to complex or recurrent pilonidal sinus: A retrospective analysis.

Pilonidal Sinus is a benign, chronic disease that affects the hair follicles of the natal cleft of the sacrococcygeal area. Its ideal treatment is controversial, especially in complex or recurrent cases. The aim of this study is to evaluate the use of minimally invasive endoscopic approach in this setting. We enrolled patients affected by complex or recurrent sacrococcygeal pilonidal sinus from January 2015 through December 2020 who underwent Video-Assisted Ablation of Pilonidal Sinus. All patients enrolled were re-evaluated once a year with a standard physical examination. The patients included were 38. Recurrence rate at 1-, 3- and 5-years follow-ups were 28.9%, 22.2% and 38.1% respectively. Of interest, the mean (SD) distance from the most lateral orifice to the midline was higher in group of patients with recurrence and the multivariate analysis demonstrated that it was the limiting factor, which influences the recurrence rate. In complex or recurrent pilonidal sinus disease with pits off the midline the endoscopic approach should not be the first choice. This makes us think that these cases should have their own classification to be identified and guide surgeons in choosing the appropriate approach.

Relaparoscopy in the management of post-operative complications after minimally invasive gastrectomy for gastric cancer.

Laparoscopy has already been validated for treatment of early gastric cancer. Despite that, no data have been published about the possibility of a minimally invasive approach to surgical complications after primary laparoscopic surgery. In this multicentre study, we describe our experience in the management of complications following laparoscopic gastrectomy for gastric cancer. A chart review has been performed over data from 781 patients who underwent elective gastrectomy for gastric cancer between January 1996 and July 2020 in two high referral department of gastric surgery. A fully descriptive analysis was performed, considering all the demographic characteristics of patients, the type of primary procedure and the type of complication which required reoperation. Moreover, a logistic regression was designed to investigate if either the patients or the primary surgery characteristics could affect conversion rate during relaparoscopy. Fifty-one patients underwent reintervention after elective laparoscopic gastric surgery. Among patients who received a laparoscopic reintervention, 11 patients (34.3%) required a conversion to open surgery. Recovery outcomes were significantly better in patients who completed the reoperation through laparoscopy. Relaparoscopy is safe and effective for management of complications following laparoscopic gastric surgery and represent a useful tool both for re-exploration and treatment, in expert and skilled hands.

Endoscopy management of sleeve gastrectomy stenosis: what we learned from 202 consecutive patients.

BACKGROUND: Gastric sleeve stenosis (GSS) is described in 1%-4% of patients. OBJECTIVE: To evaluate the role of endoscopy in the management of stenosis after laparoscopic sleeve gastrectomy using a standardized approach according to the characteristic of stenosis. SETTING: Retrospective, observational, single-center study on patients referred from several bariatric surgery departments to an endoscopic referral center. METHODS: We enrolled 202 patients. All patients underwent endoscopy in a fluoroscopy setting, and a systematic classification of the type, site, and length of the GSS was performed. According to the characteristics of the stenosis, patients underwent pneumatic dilatation or placement of a self-expandable metal stent or a lumen-apposed metal stent. Failure of endoscopic treatment was considered an indication for redo surgery, whereas patients with partial or complete response were followed up for 2 years. In the event of a recurrence, a different endoscopic approach was used. RESULTS: We found inflammatory strictures in 4.5% of patients, pure narrowing in 11%, and functional stenosis in 84.5%. Stenosis was in the upper tract of the stomach in 53 patients, whereas medium and distal stenosis was detected in 138 and 11 patients, respectively, and short stenosis in 194 patients. A total of 126 patients underwent pneumatic dilatation, 8 self-expandable metal stent placement, 64 lumen-apposed metal stent positioning, and 36 combined therapy. The overall rate of endoscopy success was 69%. CONCLUSION: GSS should be considered to be a chronic disease, and the endoscopic approach seems to be the most successful treatment, with a prolonged positive outcome of 69%. Characteristics of the stenosis should guide the most suitable endoscopic approach.

Iatrogenic biliary leak treated by performing exploratory laparoscopic using indocyanine green (ICG) fluorescence. A case report and review of literature.

INTRODUCTION: Cholangiography with indocyanine green fluorescence (ICG) is increasingly used to visualize the bile duct anatomy during laparoscopic cholecystectomy. Biliary leaks are rare complications after laparoscopic cholecystectomy, result could be lethal. Lesion's site is not always visible. We present an interesting case of a patient with biloma due to an iatrogenic lesion of the biliary tract, treated in urgency using ICG fluorescence. To our knowledge, this is the only case in the literature. CASE PRESENTATION: A 62-years-old patient after 7 days from laparoscopic cholecystectomy presented abdominal pain and fever. Blood tests showed an increase of inflammation indexes. Abdominal US and abdominal CT revealed a conspicuous right sub-hepatic fluid. We performed a laparoscopy using ICG fluorescence to find the biliary leak. Operative time of surgery was 60 min. There were no complications during this procedure. CONCLUSIONS: ICG is a safe and effective procedure that enables real-time visualization of the biliary system. In some cases, it can also be used in urgent surgery, where the biliary anatomy is much more complex. KEY WORDS: Biloma, Indocyanine green fluorescence, Iatrogenic biliary leaks, Urgent surgery.

Laparoscopic atypical resection of subcardial gastric GIST guided by intraoperative endoscopy. A single-center study and a review of the literature.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. They are 1% of all gastrointestinal cancer and 60% of them affects the stomach. Up to 10% to 30% of GISTs are malignant. They occur in people over the age of 50 in both sexes. The most common symptoms of gastric GIST are bleeding, dyspepsia, vague abdominal pain or discomfort, and mass palpation. Some are asymptomatic and diagnosed incidentally. The first choice of treatment for primary localized gastric GISTs is surgery. The most suitable type of resection is not yet clear and it depends on size and location of tumor, especially for difficult localizations, such as subcardial, posterior wall and less curvature GISTs. METHODS: We report a rare case of a patient with subcardial gastric GIST treated with laparoscopic atypical quadrangular resection guided by intraoperative endoscopy. Furthermore, we performed a review of the literature about this topic. RESULTS: Despite the difficult localization an atypical resection of the gastric GIST was performed without breaking the lesion but preserving the lumen of the esofagogastrich junction. CONCLUSIONS: An atypical quadrangular resection for subcardial gastric GISTs, located along the posterior wall and lesser curvature, can be a safe and reliable alternative technique. However, we believe that it should be performed by an experienced surgeon and endoscopist to decrease the risk of mass's break and the narrowing of the cardial region's lumen. In our literature's knowledge there aren't cases treated with this technique. KEY WORDS: Gastric GIST, Gastrointestinal stromal tumors, Intraoperative endoscopy, Laparoscopic resection, Minimally invasive surgery.

The Role of Intraoperative Indocyanine Green (ICG) and Preoperative 3-Dimensional (3D) Reconstruction in Laparoscopic Adrenalectomy: A Propensity Score-matched Analysis.

BACKGROUND: Laparoscopic adrenalectomy (LA) is considered the "gold standard" treatment of adrenal lesions that are often coincidentally diagnosed during the radiologic workup of other diseases. This study aims to evaluate the intraoperative role of indocyanine green (ICG) fluorescence associated with preoperative 3-dimensional reconstruction (3DR) in laparoscopic adrenalectomy in terms of perioperative outcomes. To our knowledge, this is the first prospective case-controlled report comparing these techniques. MATERIALS AND METHODS: All consecutive patients aged≥18 and undergoing laparoscopic transperitoneal adrenalectomy for all adrenal masses from January 1, 2019 to January 31, 2022 were prospectively enrolled. Patients undertaking standard LA and those undergoing preoperative 3D reconstruction and intraoperative ICG fluorescence were matched through a one-on-one propensity score matching analysis (PSM) for age, gender, BMI, CCI score, ASA score, lesion histology, tumor side, and lesion diameter. Differences in operative time, blood loss, intraoperative and postoperative complications, conversion rate, and length of stay were analyzed. RESULTS: After propensity score matching analysis, we obtained a cohort of 36 patients divided into 2 groups of 18 patients each. The operative time and intraoperative blood loss were shorter in patients of the 3DR group ( P =0,004 and P =0,004, respectively). There was no difference in terms of length of stay, conversion rate, and intraoperative and postoperative complications between the 2 groups. CONCLUSIONS: The use of intraoperative ICG in LA and preoperative planning with 3DR images is a safe and useful addition to surgery. Furthermore, we observed a reduction in terms of operating time and intraoperative blood loss.