The role of indocyanine green in the intraoperative navigation of gastric cancer surgery: a systematic review and meta-analysis

Indocyanine green (ICG) fluorescence imaging is increasingly being recognized as promising technique for guiding surgical procedures in gastric cancer treatment. Nevertheless, current meta-analyses have not yet fully explored its impact on lymph node (LN) dissection or evaluated its effectiveness across open, laparoscopic, and robotic surgical techniques. This study aimed to investigate the potential of ICG in enhancing LN retrieval and optimizing surgical outcomes. We conducted a systematic search of PubMed, Embase, Web of Science, and the Cochrane Library for studies published from January 2010 to December 2023 that compared ICG-guided versus non-ICG gastric cancer surgery. Eligible studies included both randomized and non-randomized designs reporting LN yield and operative outcomes. Data were pooled using random-effects models. Mean differences (MD) with 95% confidence intervals (CI) were calculated for continuous outcomes, and heterogeneity was assessed via the I² statistic. Subgroup analysis was performed by surgical modality, and publication bias was evaluated using funnel plots and Egger’s test. Eleven studies (n = 2,100 patients) were included. ICG guidance significantly increased LN harvest compared to standard surgery (pooled MD = + 6 LNs, 95% CI: +4.4 to + 7.4; p < 0.001), with moderate heterogeneity (I² = 31%) and no significant publication bias. Subgroup analysis showed the greatest benefit with robotic gastrectomy, followed by laparoscopic approaches. Our meta-analysis suggests that ICG fluorescence imaging is associated with improved LN dissection in gastric cancer surgery in terms of increased yield, and this was not associated with increased surgical risk in the studied outcomes. It appeared especially beneficial in minimally invasive procedures, particularly robotics, based on limited data, and offers a safe, effective adjunct for enhancing surgical precision across approaches.