Impact of indocyanine green fluorescence imaging on margin status and Long-term outcomes in hepatectomy: A systematic review and Meta analysis: ICG technology in Hepatectomy

• ICG fluorescence guidance demonstrated numerically higher R0 resection rates, although pooled analysis showed no statistically significant superiority over conventional hepatectomy, likely reflecting a ceiling effect in modern high-quality liver surgery. • Intraoperative ICG administration showed a stronger trend toward improved margin negativity than preoperative staining, supporting the importance of real-time fluorescence visualization during parenchymal transection. • ICG-guided hepatectomy was associated with a low incidence of postoperative liver failure, with a trend toward reduced intraoperative blood loss an important factor in mitigating postoperative hepatic insufficiency. • Overall surgical complication rates were comparable between ICG-guided and conventional approaches, confirming the procedural safety of fluorescence-guided hepatectomy. • Improved overall survival (OS) and relapse-free survival (RFS) were observed in the ICG group, potentially attributable to enhanced tumor localization, optimized margin assessment, preservation of functional liver parenchyma, and reduced surgical stress. • ICG fluorescence imaging should be considered a complementary intraoperative adjunct rather than a standalone oncologic determinant, particularly valuable in minimally invasive surgery, complex anatomical resections, cirrhotic livers, and technically demanding cases within a multidisciplinary treatment framework aligned with the Barcelona Clinic Liver Cancer strategy. Indocyanine green (ICG) fluorescence imaging is increasingly used during hepatectomy to enhance intraoperative visualization of hepatic anatomy and tumor margins. This meta-analysis evaluated its impact on oncologic and perioperative outcomes compared with conventional surgery. Twelve studies involving 1,181 patients were included. The primary outcome was R0 resection. Secondary outcomes included surgical complications, liver failure, intraoperative blood loss, Pringle maneuver duration, operative time, tumor size, hospital stay, overall survival (OS), and relapse-free survival (RFS). Pooled odds ratios (OR) and standardized mean differences (d) were calculated. R0 resection rates were 89% in the ICG group and 87.9% in the non-ICG group, with low heterogeneity (I² = 21%). No significant difference was observed (OR 1.61, 95% CI 0.92–2.79; P = 0.09). Subgroup analysis demonstrated a nonsignificant trend favoring intraoperative ICG administration, while tumor-type analysis revealed a significant trend favoring ICG in patients with hepatocellular carcinoma. Rates of surgical complications (19.8% vs 20.6%) and liver failure (1.6% vs 1.0%) showed lower trend towards ICG use. No significant differences were found in blood loss, operative time, Pringle maneuver use, tumor size, or hospital stay. Long-term analysis demonstrated nonsignificant trends toward improved OS (92% vs 88%; OR 1.51; P = 0.20) and RFS (83% vs 77%; OR 1.42; P = 0.35) with ICG guidance. ICG fluorescence-guided hepatectomy is safe and feasible but does not significantly improve R0 resection or perioperative outcomes. It should be considered a complementary intraoperative adjunct within multidisciplinary hepatocellular carcinoma management rather than a standalone determinant of oncologic success.