Beyond White Light: Indocyanine-Green Fluorescence in Contemporary Pediatric Surgery

Near-infrared fluorescence imaging with indocyanine-green (ICG) improves intra-operative visualization, yet its adoption in pediatric surgery remains limited. This narrative review summarizes current pharmacological knowledge, technical principles, and clinical evidence to guide pediatric surgeons in the safe and effective use of ICG across subspecialties. Evidence from the last decade indicates a steady expansion of fluorescence-guided techniques beyond hepatobiliary procedures—where pre-operative ICG cholangiography shortens operative time and reduces bile-duct injury—to urological, oncological, thoracic, and colorectal operations. Weight-based doses of 0.25–0.5 mg/kg given 18–24 h before surgery improve biliary and tumor contrast, while intratesticular or subcutaneous injections facilitate lymphatic mapping. The “second-window” technique (1.0–5 mg/kg administered 24 h before resection) assists margin delineation in renal and hepatic tumors. Across more than 700 pediatric cases in the literature, fluorescence guidance has enhanced surgical outcomes without ICG-related adverse events. ICG fluorescence is a versatile, radiation-free adjunct that may increase precision and potentially improve outcomes in complex pediatric operations. Nonetheless, heterogeneity in age-specific dosing, limited pharmacokinetic data in neonates, and the capital cost of near-infrared platforms continue to restrict widespread use. Multicenter trials and cost-effectiveness analyses are important to establish standardized protocols and confirm long-term benefit. As these gaps narrow, fluorescence-guided surgery is likely to progress from an experimental aid to a routine component of pediatric surgical care.