Intra-operative indocyanine green (ICG) administration for surgical guidance in laparoscopic subtotal pancreatectomy for congenital hyperinsulinism: A case series

Indocyanine green (ICG)-guided surgery is gaining traction in pediatric surgery with its utilization reported in pancreatectomy for congenital hyperinsulinism (CHI). ICG can also be an adjunctive strategy to help surgeons new to complex laparoscopic surgeries. Both infants were Diazoxide-resistant diffuse CHI with ABCC8 mutations. Their surgeries were performed at 3 months of age. Patient 1: A laparoscopic subtotal pancreatectomy (85 % resection) was initially performed due to parental preference to preserve some pancreatic function. However, the patient experienced persistent hypoglycemia refractory to maximal medical management, necessitating a revision pancreatectomy. Serial low-dose intra-operative administration of ICG was used to identify vascular and biliary landmarks. However, the intra-pancreatic segment of the common bile duct (CBD) was not visualized despite multiple boluses of ICG, and thus pancreatic transection was performed at the level right of the superior mesenteric vein (SMV), accounting for a subtotal pancreatectomy (90 % resection). Patient 2: Serial low-dose intra-operative administration of ICG was used in identification and preservation of the splenic vessels during dissection and the identification of key vascular landmarks including SMV and portal vein (PV). A near-total pancreatectomy was initially attempted with serial ICG administrations to determine the level of pancreatic transection and to avoid an intra-pancreatic CBD injury. However, we were unable to identify the intra-pancreatic CBD which was buried deep within the bulky pancreatic head tissue. A subtotal pancreatectomy with pancreatic transection at the level right of the SMV (90 % resection) was performed. All surgeries were performed laparoscopically with no intra-operative complications. ICG-guidance can aid in real-time visualization of key vascular and extra-pancreatic biliary structures, potentially avoiding intra-operative injuries during laparoscopic subtotal pancreatectomy.