Near-infrared fluorescence with indocyanine green for minimally invasive hernia surgery: A systematic review and evidence synthesis

Table 1 Basic characteristics of the included studies

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: Indocyanine green fluorescence; ICG-FA: Indocyanine green fluorescence angiography; NR: Not retrievable.

Table 2 Quality assessment of the case reports¹

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

¹Q1: Were the patient’s demographic characteristics clearly described? Q2: Was the patient’s history clearly described and presented as a timeline? Q3: Was the current clinical condition of the patient on presentation clearly described? Q4: Were diagnostic tests or methods used, and were the results clearly described? Q5: Were the intervention(s) or treatment procedure(s) clearly described? Q6: Was the post-intervention clinical condition clearly described? Q7: Were adverse events (harms) or unanticipated events identified and described? Q8: Does the case report provide takeaway lessons? Y: Yes; N: No.

Table 3 Quality assessment of case series and original articles¹

Ref.	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Total score	Quality rating
Colavita et al[24], 2016	Y	Y	Y	Y	Y	Y	Y	Y	Y	9	High
Zhang et al[9], 2024	Y	Y	U	N	Y	Y	U	Y	Y	6	Fair
Ahmed et al[20], 2022	Y	Y	N	N	Y	Y	U	N	Y	5	Fair
Aarsh et al[13], 2024	Y	N	N	N	Y	U	N	N	N	2	Low

¹Q1: Was the study question or objective clearly stated? Q2: Was the study population clearly and fully described, including a case definition? Q3: Were the cases consecutive? Q4: Were the subjects comparable? Q5: Was the intervention clearly described? Q6: Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants? Q7: Was the length of follow-up adequate? Q8: Were the statistical methods well-described? Q9: Were the results well-described? Y: Yes; N: No; U: Unclear.

Table 4 Indications for intraoperative indocyanine green fluorescence imaging stratified by clinical urgency and hernia subtype

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

TEP: Totally extraperitoneal; TAPP: Transabdominal preperitoneal.