Does indocyanine green guidance alter surgeons' behavior in laparoscopic Kasai portoenterostomy and improve outcomes?

BACKGROUND: The effect of indocyanine green (ICG) guidance during laparoscopic Kasai portoenterostomy (Lap-KPE) on intraoperative decision-making and postoperative outcomes remains unclear. This study evaluated whether ICG guidance influences surgical behavior and short-term outcomes. METHODS: Consecutive patients who underwent Lap-KPE between 2010 and 2025 were retrospectively reviewed. JF was defined as a serum total bilirubin level <1.2 mg/dL at any time after surgery. Short-term NLS was assessed at 1 year postoperatively. Operative video recordings were reviewed to identify additional cuts guided by ICG fluorescence at the porta hepatis following initial transection. RESULTS: Thirty-five patients were included, of whom 12 (34.3%) underwent ICG-guided surgery. Overall, JF was achieved in 27/35 patients (77.1%), with no significant difference between the non-ICG and ICG groups (19/23, 82.6% vs 8/12, 66.7%; p = 0.40). The 1-year NLS rate was 25/35 (71.4%), without a significant difference between groups (73.9% vs 66.7%; p = 0.70). After adjustment for age at operation, ICG guidance was not significantly associated with JF (adjusted OR 0.47, 95% CI 0.08-2.60; p = 0.385). Among ICG-guided cases, additional cuts based on ICG fluorescence were performed in 6/12 patients (50.0%), without differences in JF (66.7% vs 66.7%; p = 1.00) or 1-year NLS (66.7% vs 66.7%; p = 1.00) between cases with and without additional cuts. CONCLUSIONS: ICG guidance influences intraoperative decision-making during Lap-KPE, as reflected by additional transection, but was not associated with improved short-term outcomes. LEVEL OF EVIDENCE: Level III.