Published online May 16, 2026. doi: 10.12998/wjcc.v14.i14.118964
Revised: February 5, 2026
Accepted: March 25, 2026
Published online: May 16, 2026
Processing time: 102 Days and 5.5 Hours
Minimally invasive approaches are now established as the standard of care for the repair of many inguinal and abdominal wall hernias. Near-infrared fluorescence imaging using indocyanine green (ICG) has been widely adopted in minimally invasive surgery, enabling real-time visualisation of vascular and lymphatic anatomy. While ICG fluorescence imaging is well established for perfusion assessment and anatomical guidance in colorectal and oncological surgery, its role in hernia repair is less well defined. Evidence describing its specific applications, clinical utility, and impact on outcomes in hernia surgery remains limited.
To evaluate the role and potential clinical utility of ICG fluorescence imaging in minimally invasive inguinal and abdominal wall hernia repair.
A systematic search of PubMed/MEDLINE, EMBASE and Scopus was performed. Studies involving adult patients undergoing minimally invasive hernia repair in which intraoperative ICG was employed were included.
Seventeen studies met the eligibility criteria. The majority were single-patient case reports or small case series with methodological heterogeneity. ICG was used for: Bowel or abdominal wall perfusion and viability assessment, particularly for incarcerated/strangulated hernias, delineation of vascular/anatomical structures in inguinal hernia repair to reduce vascular injury, and lymphatic mapping to understand and potentially reduce postoperative hydrocele incidence. Dosing varied substantially, as did the timing of administration.
ICG fluorescence imaging during laparoscopic hernia repair appears safe and operationally feasible, with potential to enhance intraoperative assessment of tissue perfusion and anatomical structures. However, the current evidence base is limited to small observational studies with heterogeneous methodologies. Standardised administration and interpretation protocols, along with well-designed prospective comparative trials, are needed to determine specific clinical indications and quantify their impact on patient-centred outcomes.
Core Tip: Indocyanine green fluorescence imaging is an emerging adjunct in minimally invasive hernia repair. This systematic review synthesises 17 clinical studies and shows that intraoperative indocyanine green is feasible and has not been associated with adverse reactions, while providing real-time assessment of bowel/abdominal wall perfusion in incarcerated or strangulated hernias, improving identification of key inguinal vascular and cord structures, and enabling lymphatic mapping that may help reduce hydrocele. Evidence remains low quality and heterogeneous; standardised protocols and prospective comparative trials are needed before routine adoption.
- Citation: Pavlidis L, Geropoulos G, Kechagias KS, Psarras K, Patel V, Reza L, Prakash N, Athanasiou C, Geropoulos V, Anestiadou E, Triantafyllou T, Sapalidis K, Laskou S, Dimitroulis D. Near-infrared fluorescence with indocyanine green for minimally invasive hernia surgery: A systematic review and evidence synthesis. World J Clin Cases 2026; 14(14): 118964
- URL: https://www.wjgnet.com/2307-8960/full/v14/i14/118964.htm
- DOI: https://dx.doi.org/10.12998/wjcc.v14.i14.118964
Laparoscopic hernia repair is widely utilised for both inguinal and ventral hernias and is associated with recognised benefits, including reduced postoperative pain, shorter hospitalisation, and faster functional recovery compared with open repair[1]. However, key intraoperative challenges persist, particularly relating to accurate anatomical identification, reliable perfusion assessment, and prevention of complications such as ischaemic bowel injury or inadvertent vascular damage[2]. ICG fluorescence imaging has gained prominence as an adjunct in minimally invasive surgery. After intravenous administration, ICG binds to plasma proteins and emits fluorescence under near-infrared light, allowing dynamic real-time visualisation of tissue vascularity. Although widely used in hepatobiliary, colorectal, and re
This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, with the protocol prospectively registered on PROSPERO[6]. A comprehensive literature search was undertaken across PubMed/MEDLINE, EMBASE, Scopus, Web of Science, and the Cochrane Library for articles published from January 2000 onwards, with no language restrictions. Reference lists of eligible studies and pertinent reviews were manually screened to ensure completeness. Search strategies combined controlled vocabulary (e.g., MeSH) with free-text keywords. For example, the PubMed search incorporated terms such as “indocyanine green”, “ICG”, “fluorescence imaging”, or “near-infrared imaging” paired with “hernia repair”, “inguinal hernia”, “ventral hernia”, “incisional hernia”, or “abdominal wall reconstruction”, and terms relating to minimally invasive surgery.
Eligible studies included adults (≥ 18 years) undergoing laparoscopic or any other form of minimally invasive hernia repair, including inguinal, ventral, incisional, or other abdominal wall hernias, in which ICG fluorescence imaging was used intraoperatively. Randomised controlled trials, cohort studies, case-control studies, and case series were included. Exclusion criteria comprised review articles, conference abstracts without full reporting, animal studies, and studies lacking clinical outcome data. Primary outcomes related to the findings of intraoperative assessment of tissue perfusion, bowel viability, and vascular or lymphatic structure identification. Secondary outcomes encompassed postoperative complications (e.g., ischaemia, wound morbidity, seroma or hydrocele formation), operative duration, conversion to open surgery, and overall technical feasibility.
Two reviewers independently screened titles and abstracts before full-text assessment of potentially eligible studies. Discrepancies were resolved by consensus or referral to a third reviewer. Data extraction was performed independently by two reviewers using a standardised form capturing study characteristics (author, year, country, design, sample size), patient demographics, hernia type, operative approach, ICG dose and timing, imaging platform, indication for ICG use, and outcomes. Given the anticipated heterogeneity in study design, ICG administration protocols, imaging systems, and outcome measures, a narrative synthesis was undertaken.
The included papers were assessed for quality using the Joanna Briggs Institute Critical Appraisal Checklist for case reports[7] and the National Heart, Lung, and Blood Institute Risk of Bias Tool for case series[8]. The case reports were analysed using eight key elements: (1) Patient demographics; (2) Medical history and timeline; (3) Presenting clinical condition; (4) Diagnostic methods and results; (5) Intervention details; (6) Post-intervention outcomes; (7) Adverse events; and (8) Clinical implications. Each element was rated as “Yes”, “No”, or “Unclear”, and each report was given an overall rating. The case series was assessed in nine criteria: (1) Study objectives; (2) Study population; (3) Case selection process; (4) Subject comparability; (5) Intervention description; (6) Outcome measurement reliability; (7) Follow-up adequacy; (8) Statistical methods; and (9) Clarity of results. Similarly, each criterion was rated as “Yes”, “No”, and an overall quality rating was given.
A total of seventeen studies met the eligibility criteria (Figure 1). Five conference abstracts were excluded from the final synthesis due to their inherent limitations in methodological detail and evidence quality. Most were case reports or small case series with substantial methodological heterogeneity. Nearly all focused on inguinal hernias, with minimal representation of other abdominal wall hernia types. The study characteristics and outcomes are summarised in Table 1[9-25]. Across studies, the principal indications for intraoperative ICG use were.
| Ref. | Hernia | Reason for ICG administration | Dosage of ICG administration | Details of ICG administration (timings) | Outcomes |
| Zhang et al[9], 2024 | Inguinal | Perfusion/viability assessment; lymphatic mapping; vascular anatomy/avoid injury; anatomical delineation | 25 mg ICG diluted in 10 mL saline | Intraoperative; Intraoperatively; following this; following inguinal | Feasible/helpful; guided decisions/avoided injury or resection; complications reported/assessed |
| Nakaseko et al[10], 2023 | Inguinal | Lymphatic mapping; vascular anatomy/avoid injury | 0.25 mg; 2.5 mg; 0.25 mg | Intraoperative; following open; following endoscopic | Feasible/helpful; guided decisions/avoided injury or resection; complications reported/assessed |
| Nakashima et al[11], 2022 | Inguinal | Perfusion/viability assessment; vascular anatomy/avoid injury | 5 mg; 0.63 mg; 34.1 mg | Intraoperative; intraoperative | Feasible/helpful; guided decisions/avoided injury or resection; complications reported/assessed; no ICG-related adverse events |
| Ryu et al[12], 2016 | Inguinal | Perfusion/viability assessment; vascular anatomy/avoid injury | 5 mg | Intraoperative; intraoperative | Feasible/helpful; guided decisions/avoided injury or resection |
| Aarsh et al[13], 2024 | Inguinal | Perfusion/viability assessment; vascular anatomy/avoid injury; anatomical delineation | NR | Intraoperative | Feasible/helpful; guided decisions/avoided injury or resection; complications reported/assessed |
| Shimada et al[14], 2022 | Inguinal | Perfusion/viability assessment; lymphatic mapping; vascular anatomy/avoid injury; anatomical delineation | 2.5 mg; 5 mg; 0.25 mg | Intraoperative; intraoperative; intra-operative; prior to laparoscopic | Feasible/helpful; guided decisions/avoided injury or resection; complications reported/assessed; no ICG-related adverse events |
| Daskalopoulou et al[15], 2018 | Inguinal | Perfusion/viability assessment; lymphatic mapping; anatomical delineation | NR | Intraoperative; intraoperative; following hernia; following injection | Feasible/helpful; guided decisions/avoided injury or resection; complications reported/assessed; no ICG-related adverse events |
| Nakaseko et al[16], 2023 | Inguinal | Perfusion/viability assessment; lymphatic mapping; vascular anatomy/avoid injury; anatomical delineation | NR | Intra-operative; intra-operative; intra-operatively; prior to surgery | Feasible/helpful; guided decisions/avoided injury or resection; complications reported/assessed; no ICG-related adverse events |
| Todeschini et al[17], 2024 | Inguinal | Vascular anatomy visualization; prevention of iatrogenic vascular injury; anatomical delineation | NR | Intravenous; intraoperative; before peritoneal dissection; repeated before mesh fixation | Feasible/helpful; clear visualization of iliac and spermatic vessels within 45 seconds; guided surgical decisions; no complications reported |
| Yodying[18], 2024 | Left paraduodenal hernia (strangulated) | Bowel perfusion intra-operatively to guide resection decision | NR | Intraoperative | Guided decision on bowel resection, laparoscopic repair achieved despite challenging presentation, no ICG-related adverse events reported |
| Wormer et al[19], 2016 | Complex abdominal wall reconstruction | Assess tissue perfusion to reduce wound complications | NR | ICG-FA performed after repair and before flap closure; surgeons blinded vs non-blinded to imaging | ICG-FA identified hypoperfused areas; modification did not significantly reduce wound complications (15.6% vs 12.5%) |
| Ahmed et al[20], 2022 | Mixed surgical cases, including hernia repairs | Assess vascularity, bowel viability, lymphatic mapping, and flap vascularity | NR | Intraoperatively | Feasible across procedures; potential for improved anatomic/vascular assessment; hernia-specific outcomes not separately reported |
| Tsuchiya et al[21], 2022 | Hernia | Intestinal perfusion assessment: Evaluation of bowel and mesenteric blood flow | NR | Intraoperative; intravenous; during laparoscopic parastomal hernia repair | Feasible/helpful; confirmed adequate intestinal perfusion; guided safe repair; no postoperative complications; no recurrence at 6 months |
| Glanzer et al[22], 2021 | Hernia | Identification and protection of ureters | NR | Intraoperatively, intraurethral injection | Feasible/helpful; guided decisions/avoided injury |
| Kozadinos et al[23], 2021 | Hernia | Perfusion/viability assessment | NR | Intraoperatively; IV | Feasible/helpful; guided decisions/avoided resection (excellent perfusion, no resection needed) |
| Colavita et al[24], 2016 | Hernia | Perfusion mapping to predict wound complications | 0.25 mg | Intraoperatively, IV; performed twice: Prior to incision and prior to closure | Strong predictor of wound complications; significant association between poor perfusion and complications |
| Cengiz et al[25], 2017 | Hernia | Perfusion/viability assessment | 5 mg | Intraoperatively; IV | Feasible/helpful; guided decisions/avoided resection |
ICG fluorescence allowed identification of non-perfused bowel or abdominal wall tissue, providing objective support in determining the need for intestinal resection. This was especially relevant in incarcerated or strangulated hernia cases[9,10]. Studies reported that ICG findings sometimes corroborated clinical judgement, while in other cases they altered management by revealing unexpected ischaemia.
During inguinal hernia repair, ICG enabled visualisation of critical structures, such as the inferior epigastric vessels and spermatic cord components, potentially reducing the risk of iatrogenic injury. This has been demonstrated in both totally extraperitoneal and transabdominal preperitoneal (TAPP) repairs[11,12].
ICG identified spermatic cord lymphatics, offering insight into postoperative hydrocele formation. Preservation of these structures may reduce hydrocele rates, though larger studies are needed[13]. Across all included studies, ICG use was feasible, required minimal additional operative time, and was not associated with adverse reactions. However, protocols for dosing, timing, and interpretation were inconsistent.
The methodological quality of the included studies showed variability primarily driven by the study design. Case reports, which constituted the majority of the literature, were generally rated as good to high quality (median total score: 7/8). These studies consistently provided clear descriptions of patient demographics (Q1), surgical interventions (Q5), and final outcomes (Q6). However, a common limitation across clinical reviews was the lack of detailed reporting on adverse events (Q7) and standardized long-term follow-up, a characteristic inherent to single-case publications. In contrast, original articles and case series demonstrated a wider range of quality (Table 2). The prospective, blinded study by Colavita et al[24] was the only study rated as high quality (9/9), featuring clear study questions, comparable subjects, and detailed statistical methods. Other smaller case series[4,9] were rated as fair quality (total score: 5-6/9) primarily due to retrospective design, unstated consecutive case enrollment (Q3), and the absence of a comparable control group (Q4). This highlights the current methodological landscape, where a large number of individual case experiences contrast with a limited number of high-quality comparative studies in ICG application for hernia surgery (Table 3).
| Ref. | Q1 | Q2 | Q3 | Q4 | Q5 | Q6 | Q7 | Q8 | Total score | Quality rating |
| Glanzer et al[22], 2021 | Y | Y | Y | Y | Y | Y | Y | Y | 8 | High |
| Kozadinos et al[23], 2021 | Y | Y | Y | Y | Y | Y | N | Y | 7 | Good |
| Cengiz et al[25], 2017 | Y | Y | Y | Y | Y | Y | N | Y | 7 | Good |
| Todeschini et al[17], 2024 | Y | Y | Y | Y | Y | Y | N | Y | 7 | Good |
| Nakashima et al[11], 2022 | Y | Y | Y | Y | Y | Y | N | Y | 7 | Good |
| Shimada et al[14], 2022 | Y | Y | Y | Y | Y | Y | N | Y | 7 | Good |
| Nakaseko et al[10], 2023 | Y | Y | Y | Y | Y | Y | N | Y | 7 | Good |
| Tsuchiya et al[21], 2022 | Y | Y | Y | Y | Y | Y | N | N | 6 | Good |
| Ryu et al[12], 2016 | Y | Y | Y | Y | Y | Y | N | Y | 7 | Good |
| Daskalopoulou et al[15], 2018 | Y | Y | Y | Y | Y | Y | Y | Y | 8 | High |
| Yodying[18], 2024 | Y | Y | Y | Y | Y | Y | N | Y | 7 | Good |
| Atwood et al[31], 2021 | Y | Y | Y | Y | Y | Y | N | Y | 7 | Good |
| Nakaseko et al[16], 2023 | Y | Y | Y | Y | Y | Y | N | Y | 7 | Good |
This systematic review demonstrates that ICG fluorescence imaging is a feasible and safe adjunct during laparoscopic hernia repair, with potential utility across several domains. First, ICG enables real-time assessment of bowel and tissue perfusion in incarcerated or strangulated hernias. In several reports, fluorescence corroborated clinical judgement, while in others it altered management by revealing occult ischaemia, thereby informing decisions regarding bowel resection[26]. Table 4 summarises the proposed clinical indication of ICG use in hernia operations. Second, ICG enhances anatomical and vascular delineation during inguinal hernia repair, improving identification of critical structures, in
| Clinical context | Inguinal hernia | Ventral/incisional hernia | Complex abdominal wall (e.g., parastomal, large/redo/robotic reconstructions) |
| Elective | Anatomical/vascular delineation: Identification of inferior epigastric vessels, cord structures, and dissection planes during TEP/TAPP; lymphatic mapping: Visualization of spermatic cord lymphatics | Perfusion assessment: Evaluation of abdominal wall/skin-flap perfusion to inform incision planning, flap design, and mesh placement in selected cases; anatomical delineation: Adjunctive mapping of vascular territories in abdominal wall reconstruction | Perfusion assessment: Mapping perfusion of mobilized tissues/flaps and abdominal wall domains during reconstruction; anatomical delineation: Adjunct identification of critical structures (e.g., ureter/vascular structures) when anatomy is distorted, or dissection is extensive |
| Emergency (incarcerated/strangulated) | Perfusion/viability assessment: Real-time appraisal of bowel perfusion after reduction to support intraoperative judgement regarding resection vs preservation; anatomical delineation (selected cases): Clarification of vascular anatomy in inflamed or distorted planes | Perfusion/viability assessment: Assessment of compromised bowel or abdominal wall tissue after reduction of incarcerated/strangulated ventral/incisional hernias; perfusion assessment: Evaluation of threatened skin/soft tissue in contaminated or high-risk settings (selected cases) | Perfusion/viability assessment: Evaluation of bowel perfusion in complex reductions (e.g., parastomal or large hernias) where viability is uncertain; anatomical delineation (selected cases): Identification of ureter or other critical structures during difficult reductions or redo operations |
Beyond vascular assessment, ICG has also shown value in lymphatic mapping. Visualisation of spermatic cord lymphatics has been implicated in reducing postoperative hydrocele formation by enabling their preservation, although this remains an emerging field requiring further validation[13,18]. Despite these promising applications, evidence quality remains limited. The predominance of small observational studies, lack of comparator groups, and inconsistent reporting of outcomes hinder definitive conclusions. Significant heterogeneity exists in ICG administration protocols, operative techniques, and imaging platforms. Fluorescence interpretation is largely qualitative, with no agreed thresholds for viability or perfusion adequacy. Although adverse events were rare, systematic reporting was limited. Additional evidence presented at recent surgical conferences further highlights the potential of ICG. These reports describe its use in delineating ischaemic bowel during emergency TAPP repair, identifying necrotic segments in strangulated hernias, and visualising the ureter during complex hernia reductions, reinforcing its role as a dynamic intraoperative decision-making tool[13].
Several limitations were evident across the included studies. Most comprised small observational series or single-centre experiences, limiting the generalisability of findings. Heterogeneity in ICG dose (fixed vs mg/kg), timing, fluorescence interpretation (qualitative vs subjective), and imaging technology precluded quantitative synthesis. Only a minority of studies reported long-term outcomes, and confounding by indication was common, as ICG tended to be used selectively when viability or anatomy was uncertain. These factors collectively restrict the strength of conclusions that can be drawn.
Conference abstracts, although of low quality of evidence, provide additional early support for the intraoperative value of ICG in minimally invasive hernia surgery. Reports describe its usefulness in assessing bowel viability during emergency repairs, confirming adequate perfusion after reduction of strangulated hernias and guiding decisions on resection when occult ischaemia is detected. In more complex presentations, ICG has also been used to enhance anato
ICG fluorescence imaging appears to be a feasible and safe adjunct during laparoscopic hernia repair that may support intraoperative assessment in selected situations, particularly when bowel or tissue viability and key anatomical structures are uncertain. However, current evidence is limited and largely observational, and demonstrated clinical benefit remains unproven; therefore, the available data are insufficient to support routine adoption. Future research should prioritise high-quality prospective comparative studies, ideally randomised where feasible, using standardised dosing, timing, and fluorescence interpretation protocols. Clinically meaningful endpoints - including bowel salvage, need for resection, conversion to open surgery, vascular or lymphatic injury, wound morbidity, recurrence, and cost-effectiveness - should be consistently reported, and multicentre registries may facilitate robust data capture and the development of best-practice guidance. Until such evidence is available, ICG should be considered an adjunct that may enhance, but does not replace, surgical judgement.
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