Near-infrared imaging with indocyanine green fluorescence for intraoperative lymphatic assessment in rectal cancer surgery: a systematic review

INTRODUCTION: At present, harvesting more lymph nodes is considered more conducive to the prognosis of colorectal cancer surgery. The recent development of enhanced surgical visualization has led to the wide employment of indocyanine green (ICG) to assist minimally invasive surgery. This systematic review aims to provide a wide and critical overview of the current state of the art of ICG lymphography during rectal surgery, by focusing on the most relevant literature on this topic. EVIDENCE ACQUISITION: After validation and registration in the PROSPERO international prospective register of systematic reviews on the 5th May 2024 (ID: CRD42024539426), 8 publications have been considered relevant for the research query and have been divided into two groups: lateral pelvic lymph node dissection (LPLND) and lateral pelvic sentinel lymph node biopsy (LPSLNB). A meta-analysis has not been performed due to the low statistical significance. EVIDENCE SYNTHESIS: ICG lymphography seems to improve the number of harvested lateral pelvic lymph nodes, to reduce intraoperative blood loss and hospital length of stay during LPLND. In LPSLNB the detection rate of lateral pelvic sentinel lymph nodes ranged from 91.3% to 92%. CONCLUSIONS: ICG lymphography for fluorescence guidance for LLND is a feasible and safe technique, with promising application in terms of the number of harvested lymph nodes and post-operative outcomes improvement during rectal oncological surgery. As some of these benefits have been already suggested by the current literature, they need to be confirmed in larger and randomized clinical.