Approximately 80 per cent of hepatocellular carcinoma (HCC), the most common type of liver cancer, occurs in sub-Saharan Africa and East Asia. For many of these patients, surgery offers the best chance of long-term survival or cure.
However, liver resection requires a delicate balance: removing all cancerous tissue while preserving enough healthy liver to maintain function.
Achieving that balance can be difficult, particularly during minimally invasive procedures where surgeons work through small incisions and rely heavily on imaging to guide decision-making.
This is where fluorescence-guided surgery is rapidly becoming a valuable tool. First synthesised in 1955 by Kodak Laboratories for use in photography, indocyanine green (ICG) is a dye that makes blood flow, lymph nodes, and even tiny bile ducts visible in real time. When paired with modern imaging systems, the effect is striking - structures that were once invisible to the naked eye appear with clarity and precision.
Supporting Safer and More Precise Liver Surgery
When ICG is given before liver surgery as part of functional liver testing, it can enhance detection of intraoperative liver lesions that may not have been otherwise detected in preoperative imaging. Furthermore, it enables real-time visualisation of segmental boundaries and tumour margins, improving both partial and anatomical resections. For patients, this can translate into more precise resections, lower risk of complications and potentially better long-term outcomes.
This is especially important for liver surgery for Hepatocellular carcinoma (HCC), where resection of whole segments of tumour-containing liver in a precise fashion has been shown to improve surgical margins and reduce tumour recurrence. In such scenarios, anatomical liver resection with ICG guidance ensures more complete excision and reduces residual ischemic parenchyma, which has been linked to higher complication rates and poorer survival. In liver transplantation or cancer surgery, the unique property of ICG clearance in the bile ducts has assisted in precise delineation of bile duct anatomy. These same properties of ICG also allow assessment of bile leaks at the end of liver resection, allowing potential complications to be identified and addressed before closing the operation.
Expanding Possibilities for Liver Cancer Surgery
While fluorescence guidance is already changing day-to-day practice, ongoing advances are further improving how surgeons care for patients. Preoperative 3D reconstruction with specialised software allows the surgeon to more accurately plan surgical resections and endoscopic systems with improved near-infrared sensitivity and overlay functions are making fluorescence guidance more reliable, particularly for deep or poorly defined lesions.
Quantitative fluorescence, which measures signal intensity over time to create objective perfusion metrics, is another point of exploration. By moving from subjective visual judgment to data-driven assessment, quantitative approaches could standardise perfusion evaluation and improve prediction of complications.
Such developments may enable more personalised and precise treatment approaches for patients with complex liver tumours.
Noteworthy trends in FGS in liver surgery
Across the Asia-Pacific, fluorescence-guided surgery (FGS) with ICG is gaining strong momentum, particularly within academic institutions. The region now accounts for over 40% of global publications in this field, a clear signal of both clinical curiosity and commitment to advancing the technology. Two trends stand out in shaping its trajectory: the rise of robotic systems and the spirit of regional collaboration.
The Shift Toward Robotic Systems
Across specialties, surgeons are steadily moving toward robotic platforms, even as current outcome data show mixed results from conventional laparoscopy. Besides clinical and patient outcomes, the robotic systems have an impact in the surgeon experience. Robotic-assisted systems improve ergonomics by allowing surgeons to operate from a seated console, reducing fatigue during lengthy, high-stakes procedures. They also flatten the learning curve: if mastering laparoscopy could be compared to “chopstick” movements, robotics replaces rigid instruments with wristed tools that mimic natural hand motions, essentially giving surgeons “hands inside the body.”
This combination of enhanced dexterity, precision, and comfort is particularly powerful when paired with ICG-guided imaging. For complex reconstructive hepato-pancreato-biliary (HPB) procedures, surgeons consistently report that robotics not only enhances visualisation but also makes the entire workflow more sustainable. It is, however, clear that robotic systems are to be considered an extension of the armamentarium of the minimally invasive HPB surgeon alongside laparoscopic approaches as boundaries of what is possible to be done via MIS continue to be challenged.
Regional Collaboration
Asia’s tight-knit surgical community also fuels innovation by spreading new protocols rapidly. The Shanghai Consensus, developed by 13 hepatobiliary surgeons, represents a landmark in codifying recommendations for ICG use. Regional meetings such as the International Society for Fluorescence-Guided Surgery (ISFGS) annual congress further strengthen these networks, allowing specialties to cross-pollinate ideas and share refinements in real time.
Singapore also provides a unique test bed for such innovations with its reputation for good governance and high surgical technical capabilities. Its well-connected surgical community, coupled with a mix of high-volume public hospitals and well-equipped private centres, creates fertile ground for innovation. Through the work of the Hepato-Pancreato-Biliary Association (Singapore), the local HPB community gathers regularly to share best practices with the ultimate goal of improving patient care. When one institution finds a more effective way to apply ICG, word spreads quickly, allowing the same approach to be adopted across several hospitals.
Challenges
While fluorescence-guided surgery is rapidly gaining ground, its widespread adoption is not without hurdles.
Gaps in training remain a major challenge. In one recent study of general surgeons in North America, nearly half of surveyed surgeons reported never having received formal instruction in ICG or near-infrared fluorescence techniques. For those unfamiliar with the technology, this lack of confidence can prevent adoption, particularly for more complex applications such as anastomotic perfusion assessment. This knowledge deficit effectively renders expensive equipment underutilised in many surgical settings. Recognising this challenge, Singapore has emerged as a regional leader in addressing the knowledge gap. Surgical teams from Singapore have established structured training programs and workshops to actively engage colleagues across Asia on ICG applications across multiple specialties.
Looking Ahead
Fluorescent dyes have travelled from research curiosity to surgical necessity in just a few decades. As minimally invasive surgical systems and quantitative imaging continue to evolve, the green glow of ICG is likely to become an even more familiar sight in operating theatres. For patients facing liver cancer, that light may translate into better outcomes and more opportunities for curative treatment.
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