Using real clinical footage, our medical director, Dr. Aarathi Cholkeri-Singh explains fluorescence-guided imaging can reduce the risk of bile duct injury in a lap chole, ensure adequate bloodflow for colorectal anastomosis, aid in mapping sentinel lymph nodes, and more. the two of us have spent the last several months really looking at all of the clinical advantages across multiple specialties, some of which has been very interesting. Some eye opening. But before we get started, Doctor, tell Kerry, would you mind briefly describing what Indusind nine green is and how it works? There is a fantastic video done by Diagnostic Green and the International Society of Fluorescence guided surgery that we can use as a great visual guide. Yes, of course. Libby Indusind nine Green or I C. G. As you stated as a medical fluorescent dye that is used as an indicator for diagnosis in the visible light spectrum, our eyes can see certain colors are rainbow colors. We cannot, however, see in the range of near infrared. When I see G is stimulated by near infrared light, it becomes fluorescent, and any tissue containing I C G becomes immediately visible using specially designed cameras. The technology of these cameras allows us to see the contrast and tissue definitions that we cannot see in white light imaging that we traditionally used during surgery. For example, I C G is excreted in the bile. Therefore, after a period of circulation in the bloodstream. The structures that contain biles, such as the bile ducts, will become visible with the near infrared light as well. To use ice E g. The solution is reconstituted with sterile water in preparation for injection. After the injection is being administered intravenously, I C g binds to plasma proteins, mainly albumin, and then is delivered in tow, all parts of the body through the bloodstream. So, as you can see from this animation, the blood vessels and organs become well defined with BCG injection. The value of I C. G with near infrared light is that it safely allows for visualization of these specific structures and can provide an assessment of blood flow in many parts of the body. Thank you so much for the overview. So now that we understand what iceberg is, how about we talk about where it matters and how it makes a difference in patient care? Absolutely. Let's start our conversation with one of the most common procedures the laproscopic colossus ectomy. We know with this procedure that it's very important to properly visualize the biliary anatomy due to the consequences. Often unexpected injury. Can you take us through that the first video and talk about how I, C G and systems like Rubina can not only improve visualization but can also potentially change patient outcomes. Surely be I reviewed. Many published studies for Laproscopic will assist ectomy and realize that while bile duct injuries are relatively low, they still do occur, and they do impact patient outcomes. Unfortunately, in one of the most recent studies, Dr Dip and his colleagues conducted a prospective multi center randomized international trial, and they demonstrated that key critical structures could be identified more clearly by a factor of nearly three. When using ice e g For us, it's I want to show you a video that I think will help us to better understand their conclusion. Here we can see the gall bladder is held up on traction. One of the features of Reuben I especially appreciate with this video is the demonstration of the ductile structures with the I C. G. In overlay mode, it is extremely helpful. Thio operate in white light as that is the standard image in light surgeons air used to operating in. So with the combination of I C G overlay and white light, all the surrounding an atomic structures can be appreciated while highlighting the key anatomy of concern to aid in the surgical procedure. What we're seeing in this video is that the surgeon is trying to identify between the cystic duct, common hepatic duct and the common bile duct. The cystic duct is short, and therefore any misidentification can lead to injury of the other ducks. The fluorescents allows for contrast and definition to enable the surgeons operate around and isolate these structures. Here we can see the cystic duct and artery well isolated. Remember Libya? I told you that I C g goes through the blood vessels first. Well, the reason why we don't see the die in the cystic artery at this point of the procedure is because I see G was injected 45 minutes ago that I already went through the bloodstream and is now concentrated in the bile ducts. But we can see the cystic artery pulsating very clearly in the video. After being able to identify and isolate all the structures in the area of interest, the surgeon can now proceed with the coolest ectomy and likely reduce the risk of a common bile duct injury. That's really a great image. I especially like how well I c g per fuses along with the definition of the anatomy. And this is all while the surgeon continues to operate in white light. I agree, Libby. Now let's shift a bit and talk about another area where we've seen a lot of positive results. Riel time assessment of blood flow or profusion in laparoscopy. This is most beneficial when you're reconnecting, tissue are performing in a nasty Moses where generally leaks tend to be a major concern. Can you take us through the next segment and talk about the role of iceberg? First, let me define when it s demonic. Leak is for some patients, a portion of bowel, stomach or esophagus may be removed, which leaves a gap in that tissue, and those tissue ends around that gap have to then be reconnected. That's an anastomosis. If the anastomosis line does not have good blood supply to it, then it won't heal properly, causing those edges to not seal together and then the contents on the inside to leak out. Therefore, the use of I C G in real time enables the surgeon toe identify that there is adequate blood flow to the tissue before creating the anastomosis. While we look at the following sigmoid resection video, you can see profusion clearly demonstrated with I c G. Without I c g. It can be difficult to differentiate tissue that has poor blood supply versus healthy tissue just based on the color difference alone. Pay attention to what you can see when we switch over the monochromatic mode. There is a clear demarcation between the areas with good blood flow versus the area with less highlighted blood vessels. The contract that the contrast this mode provides is incredible and cannot be seen with the naked eye. This additional information can not only change the surgical plan but ultimately help reduce the incidence of a nasty Matic leaks. In fact, literature and colorectal surgery has shown when using ice E g. The leak risk reduction rate is about 44% and the change in the plan transaction line was around 19% which are quite significant, although not as robust, and publications and findings. We are seeing some similar positive outcomes for Asafa Jill, a nasty Moses and bariatric gastrectomy procedures. I have to say doctor shall carry through our whole review process, the risk reduction rates were the most surprising. You can really see now to how the contrast of the black and white in the monochromatic mode really can help surgeons assess blood flow and why nearly 20% of surgical plans were changed in real time based on what they saw with iceberg. Now let's shift to another area where I C G has been used for some time neurosurgery. However, traditionally, this has been with a microscope. This is where Carl Stores is really unique. We have a four millimeter I C G scope that allows surgeons to enter and operate through the nose to access the skull. And with iceberg, they can now locate blood vessels, identify anatomical structures, NSS, flat profusion. Can you take us through the next video so we can see some of this for ourselves? Yes, of course. Libby. It's so exciting to see the progression of endoscopic school based procedures in neurosurgery. You mentioned blood vessels. Libby. Although the reported incidence rate is low when the most catastrophic complications is injury to the internal carotid artery, I want to show you a video that clearly demonstrates how I C g could define the internal carotid artery anatomy for the surgeon to carefully navigate around in real time. This was a case where the tumor had invaded a Sinus face, the bone and the layer covering the brain called dura mater just for orientation. The bulbous structure at 12 o'clock is the pituitary gland, and what the surgeon is touching is the tumor in the middle of the screen just underneath that planned here, you can see the internal crowded arteries and green toe left and right of the tumor and pituitary gland due to the I C G fluorescents. You can also see blood vessels progressing behind the tumor as well. Fast forward, I want to show you, is the anatomy. Once the bulk of the tumor was respected without any vascular complications, the tumor was found to be right next to and behind the internal carotid artery. Here I see G was used to not only identify the internal credit arteries, but too closely skeletonized the artery in order to optimize tumor resection. An alternative to utilizing ice e G has been the use of micro Doppler systems, which allows the surgeon to assess vessels. But by hearing the blood flow in real time. However, in I C G and overlay or monochromatic mode, this gives the clear visual confirmation of the vessel location for proceeding with more visual confidence. Another complication that I want to touch upon because it is more common is the cerebrospinal fluid leak, which most people refer to as the CSF leak. This fluid leaks from the brain through the surgery access point. If the closure or defect doesn't heal well post operatively similar to a nasty Matic leak reduction, which we discussed earlier I C. G is helpful for the profusion assessment of the nasal septal flap, which is created from tissue of the nose to cover the defect made toe access the brain. It's always so fascinating to see the same principles of how I see works in different areas of the body, which is a great segue to our next topic. Lymph node mapping and identification. This is certainly an area where there has been a lot of questions and a lot of curiosity over the last few years. We know that when you remove multiple lymph nodes, there's potential for a patient to have many postoperative side effects that could really disrupt their quality of life. This is another area where iceberg could be quite helpful. Can you not talk about how I si G helps with assessing lymph nodes? My pleasure. Libby Evaluation of lymph nodes is a crucial step in surgical staging for patients with certain cancers. However, sentinel lymph node mapping was developed to reduce these complications that you described. A sentinel lymph node is the note that's directly related to the primary tumor and is the most likely lymph node to have metastatic disease, therefore therefore by Onley removing the suspicious nodes of cancer, the surgical trauma and operating times could be reduced, resulting in better patient outcomes. The use of I C G is applicable for many different types of cancers. These include breast melanoma, colorectal, gastric, cervical and Demetria will prostate and head and neck cancers on Lee. A few small studies were identified for Asafa, Jill and bladder cancers, but they did have high detection rates as well. Let's take a look at this video that shows the public lymphatic track fluoresce ing with I C. G. Here you see the track in overlay mode and now, in monochromatic mode, another feature of the Rubina system that we haven't spoken about previously but could be useful in surgical evaluation is the intensity map. The surgeon has the ability thio use colors as a visual guide to provide information about the signal intensity of the I C G fluorescents. The color map that can be seen on the right side of the screen indicates the surgical areas that appear yellow, orange and color have a higher signal of iceberg intensity versus areas that are highlighting in blue or green. The surgeon in this video is dissecting in the space where the pelvic lymph nodes reside. Based on the signal intensity indicated by the color map, the surgeon is isolating and removing the notes that have that yellow orange color. Libby. I believe that we're going to continue to learn about intensity mapping as surgeons use this feature for a lymph node dissection. Yeah, this is a really exciting area, and I'm really looking forward to seeing the development around this topic. Doctors will carry. I have one final question for you before we wrap up. Can you talk a little bit about your own experience in the O. R. And how you embrace new technologies. Funny you asked Libby. Um, to me, technology in the operating room is constantly evolving, just like electric cars. I feel like the next greatest latest version is just always around the next corner. As a surgeon, I'm always interested in new products because if it's something that can help improve my surgical performance and patient outcomes, I'd obviously like an opportunity to evaluate it. However, if I could be really honest with you, my most biggest challenge and the most common answer I hear from my hospital administration, is that we simply cannot budget for new capital equipment. Trust me, it's not the first time I've heard that, and this is really what makes Carl stores different as an industry partner. So we heard from Mark Ambling earlier. He talked about the design philosophy of our video platform and how it really allows for our customers to have the flexibility to add new technologies like Rubina to an existing tower rather than having to purchase an entire new tower every few years. Actually, Libby, I learned over the course of time that that's one of the reasons why my hospital partnered with Carl Stores and as a surgeon that allowed me, Thio, upgrade my technology and provide better patient health care. Dr. To Carrie, thank you so much for this conversation. And for all of your insight across the various applications for I c g. It was also really helpful to see the value and how to incorporate some of the new image ing modes into surgery and show how it can better assist surgeons. It was my pleasure living to be with you here today. Thank you for having me.