Application of a new dye for near‐infrared fluorescence laparoscopy of the ureters 79 Introduction Great public attention is present for the safety of surgery, especially in laparoscopic surgery. The Dutch Health Care Inspectorate has drawn attention to this in its report of November 2007, "Risks of minimally invasive surgery underestimated"1. Colorectal surgery is the latest form of high‐volume‐surgery for which laparoscopic techniques have now widely been introduced and is considered a technically advanced procedure requiring a high level of endoscopic skills and anatomical orientation in a two‐dimensional plane. Ureteral injury during this type of surgery is rare with a reported incidence of 0.66%2, however, when it occurs, it can be a serious clinical problem possibly resulting in intra‐abdominal sepsis, renal failure and loss of renal function3. Early recognition of such injuries can be challenging because they are detected only after other, more serious injuries are addressed, which may lead to a worse outcome. Furthermore, the incidence of iatrogenic ureteral injuries was found to be significantly greater in patients undergoing laparoscopic surgery compared to open abdominal operations2,4. Hence, the prevention and early detection of ureteral injury during laparoscopic colorectal surgery is desirable. An advanced intraoperative imaging method, called near‐infrared (NIR) fluorescence imaging, can be applied for real‐time fluorescence ureteral guidance after intravenous administration of a fluorophore5. At this moment the only clinically available dye for this purpose is methylene blue. A more recently described NIR fluorophore, CW800‐CA, is another fluorophore that is excreted in urine. It has fluorescent characteristics at similar wavelengths as the clinical fluorophore indocyanine green (ICG) and this can be detected by commercially available fluorescence imaging apparatus. Therefore, this new dye may have great potential for fluorescence imaging of crucial anatomical structures. CW800‐CA is not yet FDA cleared for clinical use, but like ICG it belongs to a class of heptamethine indocyanines with low inherent toxicity6. This technical report demonstrates the concept of near‐infrared fluorescence identification of the ureters using a commercially available laparoscopic fluorescence imaging system after intravenous injection of CW800‐CA. Methods This study was conducted at the central animal facilities of Maastricht University (Maastricht, The Netherlands). Animals were used in compliance with the regulations of the Dutch legislation for animal research, and a study protocol was approved by the
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