Summary, discussion and future perspectives 167 Summary Numerous technological innovations have entered the operating room in the past decades. Especially minimally invasive surgery is associated with a continuous stream of new technological developments. Image‐guided surgery is one of the latest innovations knocking at the door of the operating room of the future1,2. Detection of vital anatomical structures (e.g. nerves, ureters, arteries, bile ducts) is of utmost importance during all kinds of surgical procedures, as anatomical misidentification of these structures may lead to iatrogenic injury. The exploration of innovative optical techniques offers a roadmap to improve intraoperative identification and characterization of these tissues. Following a systematic literature search, Chapter 2 describes six optical techniques as potential intraoperative tools for real‐time anatomical guidance in surgery: infrared‐ray imaging, fluorescence imaging, optical coherence tomography, diffuse reflectance spectroscopy, hyperspectral imaging and optoacoustic imaging. An overview is given of the most recent developments regarding these optical techniques for enhanced anatomical identification and physiological characterization. To evaluate optical techniques based on exogenous or endogenous contrasts this thesis focuses on two techniques: near‐infrared fluorescence imaging using exogenous contrasts (Part I) and diffuse reflectance spectroscopy using endogenous contrasts (Part II). Near‐infrared fluorescence‐guided laparoscopy (Part I) Laparoscopic cholecystectomy is one of the most commonly performed laparoscopic procedures. Bile duct injury is a rare but serious complication during this procedure, mostly caused by misidentification of the extra‐hepatic bile duct anatomy. Conventional intraoperative cholangiography may be helpful to reduce the risk of bile duct injury; however this is not a common procedure worldwide. Chapter 3 describes the first application of a laparoscopic fluorescence imaging system for intermittent near‐infrared fluorescence cholangiography (NIRFC) using iodine‐free indocyanine green (ICG) during elective laparoscopic cholecystectomy. This pilot study demonstrates the merit of NIRFC as an aid to obtain earlier and clearer recognition of the extra‐hepatic bile duct anatomy, compared to conventional laparoscopic imaging alone. Chapter 4 reports the possibility of concomitant vascular (i.e. cystic artery) and biliary (i.e. cystic duct and common bile duct) imaging at establishment of Critical View of Safety (CVS). Repeated ICG injection at establishment of CVS provides confirmation of arterial anatomy, in particular the course of the cystic artery. Implementation of
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