Chapter 11 conducting both fluorescence cholangiography and angiography can be helpful in cases in which the establishment of CVS is challenging. Furthermore it may facilitate the intraoperative detection of bile duct and possible concomitant vasculobiliary injury (e.g. hepatic artery). The observations in Chapters 3 and 4 show that both biliary and vascular fluorescence imaging are easily applicable in laparoscopic cholecystectomy. Despite these promising findings, optimization of this new technique is desirable with respect to the imaging system combined with the fluorophore. For example, increased penetration depth at which the imaging system can detect a fluorophore in tissues would enhance its applicability (current maximum of 1 centimeter). This also is the case for an increase in fluorescence capabilities (e.g. increased uptake by target tissue, better contrast‐to‐background signal) of contrast agents. Chapter 5 compares the performance of the pre‐clinical near‐infrared dye CW800‐CA with ICG for near‐infrared fluorescence laparoscopy of the cystic duct and artery in pigs. We demonstrated that, next to ICG, CW800‐CA can be applied for laparoscopic fluorescence identification of the cystic artery and duct using the same commercially available imaging system. Laparoscopic fluorescent identification of the cystic duct can be obtained earlier after injection of CW800‐CA than after injection of ICG. With the availability of another fluorophore (with more powerful fluorescent characteristics), the possibilities increase to further optimize the imaging capabilities of the presently available fluorescence systems. A dose‐finding and clinical feasibility study for CW800‐CA is the next step. Ureteral injury seldom occurs during laparoscopic colorectal surgery, but can cause serious problems. Therefore, the early and easy detection of the ureters and prevention of ureteral injury is clinically relevant and important. Chapter 6 describes near‐infrared fluorescence delineation of the ureters in a pig model by using a commercially available laparoscopic fluorescence imaging system and CW800‐CA. A single dose of CW800‐CA (85 g per kg bodyweight) provides clear delineation of the course of both ureters approximately ten minutes after intravenous injection. As a possible next step, we envision a clinical pilot study investigating the feasibility of near‐infrared 168 fluorescence imaging (using CW800‐CA) for intraoperative delineation of the course of the ureters. Such a future study should focus on a more targeted dose finding of the administered dye. Diffuse reflectance spectroscopy during surgery (Part II) Diffuse reflectance spectroscopy (DRS) is a non‐invasive technique measuring the characteristic reflectance spectrum produced by different tissues. The primary mechanism is absorption and scattering of the light, both varying with the wavelength
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