Publication:

Indocyanine green fluorescence angiography in reconstructive surgery: does better visualization translate into better outcomes?

Indocyanine green fluorescence angiography (ICG-FA) is an intraoperative imaging adjunct used to assess tissue perfusion in real time across multiple surgical specialties. It enables dynamic visualization of microvascular blood flow and has been proposed to reduce ischemia-related complications such as anastomotic leakage and flap necrosis. Despite increasing adoption, its definitive clinical benefit remains debated. Evidence from randomized trials and meta-analyses suggests potential reduction in complications in selected settings, particularly colorectal surgery, although results are heterogeneous in reconstructive procedures. This review evaluates physiological basis, clinical applications, limitations, and emerging developments, highlighting a gap between improved intraoperative decision-making and consistent patient-centered outcomes. A narrative review of PubMed, Scopus, and major surgical journals was performed, prioritizing systematic reviews, meta-analyses, randomized controlled trials, and high-impact observational studies. ICG-FA reliably visualizes perfusion and frequently alters intraoperative decisions. In colorectal surgery, meta-analyses show reduced anastomotic leakage. In reconstructive surgery, including breast and microsurgical flaps, it helps identify poorly perfused tissue and optimize flap design, though evidence for consistent reduction in complications remains variable. Limitations include lack of standardized quantitative thresholds, interobserver variability, limited tissue penetration, and inconsistent methodologies. Emerging technologies such as quantitative fluorescence analysis and artificial intelligence may improve reproducibility. Overall, ICG-FA is a valuable adjunct but its impact on long-term outcomes remains uncertain. Future research should focus on standardized protocols and prospective trials to better define its role in modern reconstructive and gastrointestinal surgery and to establish evidence-based guidelines for routine clinical implementation across diverse surgical specialties worldwide in high-risk patient populations particularly settings.