Uses of near-infrared light for real time image guided surgery

Barnes, T

Abstract:: Fluorescence is a technology where a fluorophore is excited by light at a specific wavelength and light is emitted at a longer wavelength and can be detected. This has been applied for imaging in surgery because in the near infra-red spectrum, light can penetrate through overlying tissue and provide information to the surgeon about underlying structures. Two important applications of fluorescence include identification of critical anatomical structures to prevent injury and guide dissection, and identification of tumours to aid diagnostics. During colorectal surgery, it is essential for surgeons to be aware of the location of the structures in the urinary tract. The ureter is an essential landmark of the correct dissection plane as well as its injury being a devastating complication. To date, fluorescence identification of the ureter has only been described in technical papers. This thesis explores ureteric fluorescence further with a large cohort of patients using methylene blue and a first in man study assessing IRDye 800BK (Chapter 3). Urethral identification with NIR light is also explored from proof of principle to in vivo assessment using methylene blue, ICG and a NIR light emitting device (Chapter 4). During oesophagectomy, the thoracic duct can be injured complicating the post-operative course with chylothorax. Fluorescence of the duct for prevention and identification of intraoperative injuries is, for the first time, described (Chapter 5). Finally, WFA as a target for sugars in the mucus is explored to highlight cancer and dysplasia during colonoscopy and TEMS. Autofluorescence in the colon provides difficulties in fluorescent imaging and is explored as well as the struggles with utilising mucus as a target with WFA. However, an additional potential marker, GPA33, could provide a future for in vivo colonic imaging.

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APA Style

Barnes, T. (2019). Uses of near-infrared light for real time image guided surgery [PhD thesis]. University of Oxford.

MLA Style

Barnes, T. Uses of Near-Infrared Light for Real Time Image Guided Surgery. 2019. University of Oxford, PhD thesis.

Chicago Style

Barnes, T. 2019. “Uses of Near-Infrared Light for Real Time Image Guided Surgery.” PhD thesis, University of Oxford.
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Files:: Thomas Barnes DPhil Thesis.pdf

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Authors

+ Barnes, T More by this author

Division:: MSD
Department:: Surgical Sciences
Role:: Author

Contributors

+ Mortensen, N

Role:: Supervisor

+ Bodmer, W

Role:: Supervisor

+ Cunningham, C

Role:: Supervisor

+ Ahmed, A

Role:: Examiner

+ Ris, F

Role:: Examiner

DOI:: 10.5287/ora-zb6xoa08v
Type of award:: DPhil
Level of award:: Doctoral
Awarding institution:: University of Oxford

Language:: English
Subjects:: Surgery

Virtual reality

Image guided surgery

Fluorescence

Fluorescence guided surgery

Molecular imaging
UUID:: uuid:64e8fece-ee57-4e8a-b308-22c8c2d02735
Deposit date:: 2019-05-10
ARK identifier:: ark:/29072/ora_64e8feceee574e8ab30822c8c2d02735

Related item:: Improved urethral fluorescence during low rectal surgery: a new dye and a new method.
Description:: BACKGROUND: The aim of this study was to demonstrate highlighting of the urethra during surgery through the use of two different methods: a new near-infrared fluorophore IRDye800BK, and indocyanine green (ICG) mixed with silicone. METHODS: Male cadavers from the department of anatomy at the University of Oxford were used to visualise the urethra during near-infrared fluorescence excitation. To assess IRDye800BK, a perineal incision was utilised after infiltrating the urethra directly with an IRDye800BK solution mixed with Instillagel. ICG-silicone was assessed when the urethra was purposely exposed as part of a simulated transanal total mesorectal dissection. ICG was previously mixed with ethanol and silicone and left to set in a Foley catheter. Fluorescence was visualised using an in-house manufactured fluorescence-enabled laparoscopic system. RESULTS: IRDye800BK demonstrated excellent penetration and visualisation of the urethra under fluorescence at an estimated tissue depth of 2 cm. An ICG-silicone catheter demonstrated excellent fluorescence without leaving any residual solution behind in the urethra after its removal. CONCLUSIONS: The newly described ICG-silicone method opens up the possibility of new technologies in this area of fluorescence guided surgery. IRDye800BK is a promising alternative to ICG in visualising the urethra using fluorescence imaging. Its greater depth of penetration may allow earlier detection of the urethra during surgery and prevent wrong plane surgery sooner.
Related item:: Fluorescence to highlight the urethra: a human cadaveric study.
Description:: BACKGROUND: Urethral injury is a complication feared by surgeons performing transanal TME (TaTME) or abdominoperineal excision (APE) procedures. Injury during TaTME occurs when the prostate is inadvertently mobilised or as a direct injury similar to the direct injury during the perineal dissection of APE procedures. We performed a proof of principle study to assess the feasibility of using indocyanine green (ICG) to fluoresce the urethra in human cadavers. METHODS: Indocyanine green at varying doses was mixed with Instillagel and infiltrated into the urethra of male human cadavers. The urethra was exposed through either a perineal incision or by mobilisation of the prostate during a TaTME dissection and fluorescence observed using a PINPOINT laparoscope (NOVADAQ). Brightness was assessed on the images using ImageJ (National Institute of Health). RESULTS: Eight cadavers were included in the study. Fluorescence was visualised in the urethra in all eight cadavers. Minimal dissection was required to obtain fluorescence transperineally. In one cadaver, the urethra was demonstrated under fluorescence using a simulated TaTME with additional fluorescence also being observed in the prostate. There was no correlation between brightness and dosing. CONCLUSIONS: This novel proof of principle study demonstrates a simple way in which the urethra may be easily identified preventing it from injury during surgery.
Related item:: Methylene blue fluorescence of the ureter during colorectal surgery.
Description:: BACKGROUND: Iatrogenic ureteric injury is a serious complication of colorectal surgery. Incidence is estimated to be between 0.3 and 1.5%. Of all ureteric injuries, 9% occur during colorectal procedures. Ureteric stents are utilised as a method to reduce the risk of injury; however, these are not without risk and do not guarantee prevention of injury. Fluorescence is a safe and effective alternative for intraoperative ureteric localisation. This proof of principle study aims to assess the use of methylene blue to fluoresce the ureter during colorectal surgery. METHOD: Patients undergoing elective colorectal surgery were included in this open label, non-randomised study. Methylene blue was administered intravenously at varying doses (0.25-1 mg/kg) over 5 min, 10-15 min prior to entering 'ureteric territory.' Fluorescence was assessed using the PINPOINT Deep Red laparoscopic system at fixed time points by the surgeon and an independent observer. RESULTS: 42 patients received methylene blue; 2 patients were excluded from analysis. Of the 69 ureters assessed, 64 were seen under fluorescence. Of these, 14 were not visible under white light. 50 ureters were observed with both fluorescence and white light with 14 of these being seen earlier with fluorescence. In ten cases, fluorescence revealed the ureter to be in a different location than suspected. CONCLUSION: Fluorescence is a promising method to allow visualisation of the ureter, where it is not identified easily under standard operative conditions, thereby improving safety and reducing operative time and difficulty.

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Licence:: Terms and Conditions of Use for Oxford University Research Archive

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Uses of near-infrared light for real time image guided surgery

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