Indocyanine Green (ICG) and Bowel Perfusion: Key Takeaways from Dr. Deep Goyal at WALS 2025

In the evolving landscape of laparoscopic surgery, advancements in intraoperative visualization have significantly enhanced surgical precision and patient outcomes. At the World Association of Laparoscopic Surgeons (WALS) 2025 conference, held earlier this year, Dr. Deep Goyal, a prominent figure in minimally invasive colorectal surgery, delivered a compelling presentation on the role of Indocyanine Green (ICG) in assessing bowel perfusion. His insights underscored the transformative potential of ICG fluorescence imaging, particularly in reducing complications such as anastomotic leakage—a persistent challenge in colorectal procedures. This essay explores the key takeaways from Dr. Goyal’s talk, emphasizing the practical applications, current evidence, and future directions of ICG in bowel perfusion assessment.

The Significance of Bowel Perfusion in Colorectal Surgery

Bowel perfusion, the adequacy of blood supply to intestinal tissue, is a critical determinant of successful anastomosis—the surgical connection of two bowel segments. Inadequate perfusion can lead to anastomotic leakage, a severe complication associated with increased morbidity, prolonged hospital stays, and higher healthcare costs. Traditionally, surgeons have relied on subjective methods to assess perfusion, such as observing tissue color, pulsation of blood vessels, or bleeding at resection margins. However, these techniques often lack precision, especially in laparoscopic settings where tactile feedback is limited. Dr. Goyal highlighted this limitation, noting that even experienced surgeons can misjudge perfusion, leading to preventable complications. Enter ICG, a fluorescent dye that, when paired with near-infrared (NIR) imaging, offers a real-time, objective visualization of blood flow—a game-changer in the operating room.

How ICG Enhances Intraoperative Decision-Making

Dr. Goyal’s presentation centered on the mechanism and application of ICG fluorescence imaging. Administered intravenously, ICG binds to plasma proteins and emits fluorescence under NIR light, allowing surgeons to visualize vascular perfusion instantly. In laparoscopic colorectal surgery, this technology enables precise identification of well-perfused tissue prior to anastomosis. Dr. Goyal shared case examples from his practice where ICG imaging prompted adjustments to the resection line—decisions that might have been overlooked with conventional methods. For instance, in a patient undergoing a low anterior resection, ICG revealed a poorly perfused segment despite a healthy appearance under standard light, leading to a more proximal transection and, ultimately, an uneventful recovery.

This ability to adapt intraoperative strategy is one of ICG’s most significant advantages. Dr. Goyal emphasized that the technology not only confirms adequate perfusion but also identifies ischemic areas that could compromise healing. Studies he referenced suggest that ICG-guided adjustments occur in up to 5-10% of cases, potentially preventing leaks that traditional assessment might miss. This real-time feedback empowers surgeons to tailor their approach, aligning with the ethos of personalized medicine.

Evidence and Limitations: A Balanced Perspective

While Dr. Goyal championed ICG’s utility, he also provided a balanced view of the current evidence. Several studies, including multicenter trials, have explored whether ICG fluorescence imaging reduces anastomotic leakage rates. Results are promising but mixed. For example, in certain high-risk surgeries like rectosigmoid resections, ICG has shown a measurable decrease in leak rates—an outcome Dr. Goyal attributed to the complexity of pelvic anatomy and the critical need for robust perfusion in these cases. However, across broader colorectal procedures, large randomized trials have yet to demonstrate a statistically significant reduction in overall leakage rates compared to conventional methods.

Dr. Goyal pointed to a landmark trial from 2023, conducted in the Netherlands, where over 900 patients were randomized to either ICG-guided or standard anastomosis. The leakage rate was 7% with ICG versus 9% without, a difference that, while encouraging, did not reach statistical significance. He suggested that this inconsistency might reflect variability in surgical expertise, patient risk factors, or ICG protocols—variables that future research must standardize. Moreover, he acknowledged practical limitations: the equipment requires investment, training is essential, and fluorescence interpretation can be subjective without quantitative tools. These challenges, he argued, do not diminish ICG’s value but highlight the need for refinement.

Beyond Perfusion: Expanding Applications

A standout moment in Dr. Goyal’s talk was his exploration of ICG’s versatility beyond perfusion assessment. He discussed its emerging role in lymphatic mapping, ureter visualization, and tumor localization—applications that could further elevate its status in laparoscopic surgery. In colorectal cancer cases, for instance, ICG injected near the tumor can illuminate sentinel lymph nodes, potentially guiding more precise lymphadenectomies. While this technique remains investigational, Dr. Goyal expressed optimism about its oncologic implications, envisioning a future where ICG enhances both safety and cancer control.

He also touched on ICG’s safety profile, noting its rarity of adverse reactions and cost-effectiveness when weighed against the financial burden of complications like anastomotic leaks. This pragmatic perspective resonated with the WALS audience, many of whom practice in resource-variable settings where balancing innovation and affordability is paramount.

The Road Ahead: Standardization and Innovation

Dr. Goyal concluded with a call to action for the surgical community. He stressed the need for standardized ICG protocols—optimal dosing, timing, and imaging conditions—to ensure consistent outcomes. Current practices vary widely, with doses ranging from 5 to 10 mg and timing from 30 to 60 seconds pre-evaluation, as noted in a recent international Delphi survey. He also advocated for quantitative ICG analysis, where software could measure fluorescence intensity and perfusion parameters, reducing reliance on subjective interpretation. Such advancements, he argued, could solidify ICG’s evidence base and broaden its adoption.

Looking forward, Dr. Goyal predicted that ICG’s integration into laparoscopic surgery would grow, driven by technological refinements and accumulating data. He envisioned a synergy with artificial intelligence, where machine learning could analyze fluorescence patterns and predict anastomotic success—a prospect that drew enthusiastic discussion from the audience.

Conclusion

Dr. Deep Goyal’s presentation at WALS 2025 illuminated the transformative role of Indocyanine Green in assessing bowel perfusion during laparoscopic colorectal surgery. By offering real-time, objective insights, ICG enhances surgical precision and holds promise for reducing anastomotic complications, particularly in complex cases. While challenges remain—ranging from inconsistent evidence to practical hurdles—his balanced perspective underscored both its current value and untapped potential. As the field moves toward standardization and innovation, ICG stands poised to become a cornerstone of image-guided surgery, reflecting the relentless pursuit of better outcomes that defines modern medicine. For surgeons and patients alike, Dr. Goyal’s insights offer a compelling glimpse into a future where technology and skill converge to redefine excellence in the operating room.