Using fluorescence in minimally invasive thoracic surgery: a narrative review

Introduction

The potential uses for fluorescence imaging in minimally invasive thoracic surgery have rapidly expanded in recent years. A number of fluorescent agents and technologies exist, but indocyanine green (ICG) is most commonly used and is one of only a few Food and Drug Administration (FDA)-approved fluorescent dyes. ICG was first approved in 1959 for determining cardiac output and hepatic function, but more recently it has also been approved for visualization of vessels, blood flow, tissue perfusion, and lymphatic mapping (1). However, many surgeons across specialties use this compound “off-label” for a variety of other purposes given its ease of use, relative safety and few contraindications (2). Thoracic surgery is no exception.

Initial use of ICG required a laparoscope or thoracoscope with filters to emit and detect near-infrared light, which sometimes involved separate equipment that could pose a limitation to its use (3). Newer laparoscopic/thoracoscopic equipment and robotic platforms typically now come standard with this technology (e.g., Intuitive’s Firefly^® system) making its integration into daily practice simple. With these technical advancements, more surgeons are using this technology. Yet, few guidelines exist outlining the use of fluorescence imaging in thoracic surgery. Expert thoracic surgeon consensus recommendations are currently limited to a few uses, including identification of intersegmental planes, localization of lung nodules, lymph node mapping, and gastric conduit perfusion in esophagectomy (4), and existing reviews have focused on these limited uses and fluorescence agents (5). However, there is a growing body of literature supporting countless other uses in thoracic surgery and additional agents outside of ICG.

In this context, this narrative review aims to highlight the major uses of available fluorescence agents in thoracic surgery, including those relevant to lung, esophagus, mediastinum and other structures within the chest, while also assessing current limitations and future directions for the technology. We present this article in accordance with the Narrative Review reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-2026-1-0004/rc).

Methods

We used medical subject headings (MeSH) terms “indocyanine green“ AND “thoracic surgery” as well as “fluorescence imaging” AND “thoracic surgery” to locate relevant articles on PubMed for inclusion in this narrative review. In order to isolate the most relevant and up-to-date primary articles, we limited the search to articles published in English between January 1^st, 2010 through December 15^th, 2025 and the following article types: clinical trials, books, case reports, clinical study, comparative study, equivalence trial, evaluation study, meta-analysis, multicenter study, observational study, randomized controlled trial (RCT), and validation study. This yielded 160 total articles. Those that were excluded were non-English articles, articles focusing on cardiac or non-thoracic pathology, those that did not use minimally invasive techniques, or those focusing on other technology with only a mention of ICG or fluorescence imaging. The search strategy summary can be seen in Table 1.

Available dyes and fluorescent-related technology

Near-infrared fluorescence (NIF) technologies have been thoroughly explored in cancer research owing to its favorable biophysical properties for tumor localization and relatively safe pharmacologic profile. NIF wavelengths (700–1,000 nm) are advantageous for diagnostic imaging due to its low absorption, scatter and tissue auto-fluorescence light properties in this range (6,7). Various NIF dyes have been developed with promising sensitivity and specificity for tumor localization including cyanine, borondipyrromethene, squaraine, phthalocyanine and porphyrin derivatives (8-13).

The most commonly used dye in clinical practice is ICG. ICG is a water-soluble dye with a half-life of 150 to 180 seconds. It rapidly distributes in blood and readily binds to plasma proteins including albumin (14). Its fluorescent properties when activated by light include a peak spectral emission wavelength of 800–840 nm which appears bright green to the human eye (15). It is primarily processed by the liver and thus has historically been used in hepatic imaging (16). However, it can be used to visualize nearly any structure it is injected into. There are various routes of administration with the most common being intravenous, though others include intracutaneous, subcutaneous, endoscopic submucosal, intrabiliary, enteral, lymphatic, endobronchial, and interstitial. It is generally well tolerated with minimal side-effects; although as with any medication, allergic reactions are possible (17).

Clinical use of ICG dates back to the 1960s with applications in liver function diagnostic imaging and cardiac output monitoring (18-20). It received FDA approval in 1959 for indications of determining cardiac output, hepatic function, liver blood flow, and ophthalmic angiography. Hachey et al. detailed one of the first preliminary safety and feasibility studies on ICG lymphadenectomy during esophagectomy (21). Since that time, other agents have been developed and FDA-approved and some are still in development.

For example, there are some related dyes, such as pafolacianine (Cytalux^®). Pafolacianine is a folate analogue conjugated to an ICG-like near-infrared fluorophore that has a similar fluorescent emission range with peaks at 796 nm (22). There are distinct benefits and drawbacks to this compound. For one, it allows a simple but directed identification of pulmonary nodules via peripheral intravenous administration as it is taken up by any folate-utilizing tumor. However, this also limits use to tumors with folate receptors, and therefore, cannot be used universally.

Another compound that is actively being studied is Cetuximab-IRDye800CW, which is an ICG-type fluorophore. The RECOGNISE study evaluated the effectiveness of Cetuximab-IRDye800CW as an NIF technology to mark lung nodules and mediastinal lymph nodes. The motivation behind this trial was that conventional ICG has limited low-depth penetrance into deep tissues and therefore presents potential for missed lung nodules (23). IRDye800CW is posited to have deeper tissue penetrance and Cetuximab-IRDye800CW has previously been shown to have favorable results in tumor tracking for head, neck, brain, and pancreas cancers (24,25). However, this is not currently FDA-approved and is still being studied.

Another FDA-approved agent is 5-Aminolevulinic acid (ALA), which was approved for use in 2017. This dye has been used in intraoperative photodynamic detection of tumor tissue, primarily for high-grade gliomas (26). It is a non-protein amino acid precursor to porphyrin. 5-ALA accumulates in protoporphyrin-IX which is light-sensitive with peak spectral emission near 635 nm. However, 5-ALA applications in fluorescence-guided surgery have been predominantly described in the neuro-oncology literature with uses in thoracic surgery limited to in vivo animal models (27-34).

Other agents that are being studied are porphysomes, a nanoparticle technology comprised of porphyrin-lipid conjugates that self-organize into liposome-like bilayers. They have been found to preferentially accumulate in solid tumors due partially to an enhanced permeability and retention effect with possible tumor selectivity superior to ICG (35). Porphysome bioavailability studies have shown tissue distributions of 10:1 tumor-to-muscle ratio and good discrimination between normal lung tissue from tumor (36). Its efficiency in conversion of light energy to heat make it advantageous for photothermal therapy (37). However, studies thus far have been limited to in vivo xenograft lung cancer animal models with biophysical properties analyzed ex vivo after porphysome intravenous injection.

Therefore, at the current time, most fluorescence imaging in real-world thoracic surgery practice is limited to ICG, but there may be more dyes in the future that provide unique advantages, such as increased tissue penetration, greater concentration within tumor tissue, and use with alternative therapies. The rest of this review will focus on current real-world uses of fluorescence imaging in thoracic procedures.

Uses in lung and airway surgery

Identification of intersegmental planes

Fluorescence imaging has been extensively tested and used for sub-lobar resections of the lung. With recent publications highlighting the utility of segmentectomy for small peripheral lesions, identifying accurate intersegmental planes and obtaining adequate margins is paramount (38,39). An early clinical trial from 2010 revealed effective use of ICG in marking segmental borders in eight patients (40). A similar trial in 2014 on a larger number of patients similarly showed effective marking of intersegmental planes in ~85% of cases (41). Since that time, countless case reports have demonstrated effective use of ICG via intravenous and endobronchial injection to identify intersegmental planes, airways and vasculature in segmentectomy, and to identify aberrant anatomy during lung resection (42-52). Figure 1 shows an example of intravenous ICG injection during a right apical segmentectomy with the apical pulmonary artery branch ligated. Multiple series, clinical trials and comparative effectiveness studies have also shown specific benefits to the use of ICG in these cases. One of these studies showed that ICG allowed surgeons to more quickly identify intersegmental planes compared to the classic inflation/deflation technique (53). Others have shown improved margin lengths while avoiding unnecessary excessive parenchymal resection (54-56). Although, one study noted that margin distance was similar for ICG compared to standard identification techniques for more experienced surgeons (57). However, that study still showed more accurate identification of intersegmental planes for less experienced surgeons, so ICG remains a helpful tool in these cases for many surgeons.

Figure 1 Identification of vasculature and intersegmental plane using ICG during S1 segmentectomy. (A) Segmental artery identification. (B) Identification of intersegmental plane. ICG, indocyanine green.

Nodule localization

Fluorescence techniques can be used to localize pulmonary nodules, which can be particularly useful in minimally invasive operations when the lesions are small or are non-palpable. There are a number of different techniques for localization. An RCT compared localization with inhaled ICG versus white light localization intra-operatively and found that ICG improved localization rates and lowered operative times during resection (58). This technique has also been successfully demonstrated in case reports for a variety of lesions, including ground-glass opacities (59). Fluorescent agents given via other routes, including intravenously have also shown efficacy in localizing pulmonary nodules as the dye may stay in malignant tissues longer than healthy lung parenchyma (60-62). In fact, in one study of 36 patients, intravenous ICG helped locate an additional nine nodules that weren’t seen with white light and four of these nodules were malignant (63). ICG can also be injected directly into the peritumoral space via computed tomography (CT)-guided percutaneous injection or bronchoscopic injection with or without microcoil placement (64-67). For example, at our own institution (Loyola University Medical Center), we have used multiple different techniques. The first technique involves directed placement of an ICG-dipped fiducial (coil) via navigational bronchoscopy. This technique allows for precise localization and fluorescence that lasts for days. One example of this can be seen in Figure 2, where a dipped fiducial marker was placed three days before surgery and the fluorescence remained intense and localized through the day of surgery. The 7 mm part solid nodule was otherwise not palpable and ultimately proved to be a squamous cell carcinoma. Others have reported that this form of marking may last up to 67 days, so this represents a durable long-lasting form of localization (68). Another technique we have used is bronchoscopic injection of a mixture of methylene blue and ICG around the tumor, which allows for visualization on both white light and firefly imaging during the case, as seen in Figure 3. However, it is important to note that this injection was given on the day of surgery as fluorescence can wash out over time without a fiducial. Similar uses in the literature have shown success with combinations of ICG and lipidiol for combined fluorescence and fluoroscopic guidance (69).

Figure 2 ICG-dipped fiducial marker was placed via navigational bronchoscopy to assist with intra-operative localization of ground glass opacity. (A) CT scan showing ground glass opacity (dotted red circle). (B) Intra-operative near-infrared view of lesion marked with ICG-dipped fiducial. CT, computed tomography; ICG, indocyanine green.

Figure 3 Mixture of ICG and methylene blue was injected into the peritumoral space via navigational bronchoscopy pre-operatively. (A) Intra-operative white light view of lesion localization with methylene blue. (B) Intra-operative near-infrared view of lesion stained with ICG. ICG, indocyanine green.

When comparing techniques of ICG targeting, one retrospective study of 175 patients showed that CT-guided injection led to 98.3% success in thoracoscopic visualization of lesions (70). Similar techniques have also been successfully used for foreign body localization and resection, so this technique is not only limited to malignancies (71,72). When comparing percutaneous versus bronchoscopic techniques, one study revealed similar outcomes, although bronchoscopic injection allows the marking of multiple lesions with lower risks of pneumothorax (73). In a study of 47 patients, 35 underwent percutaneous injection with 94.3% success in lesion localization compared to 100% success in the navigational bronchoscopy group (74). Of note, 5 patients in the percutaneous group in that study developed pneumothoraces, whereas none in the bronchoscopy group developed complications, so bronchoscopic injections may provide a safer route of administration with similar or increased efficacy in nodule localization.

Some newer techniques allow for even less invasive and more targeted delivery of fluorescent molecules. For example, pafolacianine (Cytalux^®) is a folate analogue bound to an ICG-like conjugate. This compound is commonly taken up by folate receptor positive tumors, which encompass approximately 85% of lung tumors (75). In the ELUCIDATE trial, which was a multicenter RCT of pafolacianine in 112 patients with suspected or confirmed lung cancer, there were 19 patients who had tumor identified with pafolacianine that could not be identified with white light and palpation alone (75). In that study, the compound helped identify 10 occult synchronous lesions and changed the scope of resection in 29 patients (75). This technique is clearly beneficial in that administration is simple via the intravenous route, it can identify occult disease, and it can assist with real-time localization of non-palpable lesions. However, it is not effective in folate receptor-negative tumors.

Overall, the literature provides excellent evidence for multiple routes of administration, combinations of technology and fluorescent dyes for lung nodule localization. However, each has its own unique uses, benefits and drawbacks that are important to understand.

Nodal mapping

Localization is not solely limited to the lung but may also be used in sentinel node mapping or nodal metastatic disease. This may be done during navigational bronchoscopy with direct injection into the nodes or in the peritumoral space allowing for normal spread through lymphatics (67,76). One study showed that lymph node identification was successful in 23 out of 42 patients and all of these patients had pathological node-negative (pN0) disease (77). However, the 19 patients who did not have sentinel nodes successfully identified with ICG had higher recurrence rates and worse 5-year survival (77). This indicates an important point that ICG-guided identification of sentinel lymph nodes in lung cancer resection may play an important role in identifying nodes, but it is not 100% effective at identifying all sentinel nodes and occult nodal disease. Other studies have similarly shown mixed results in the overall nodal detection rates (78). Therefore, at the current time, surgeons should not rely solely on ICG to determine which lymph nodes should be dissected during lung resection and should rely on established guidelines and quality standards for nodal dissection. However, ICG may be a useful adjunct to these standard techniques.

Air leak identification

Another important use for ICG in lung resection is intra-operative identification and prevention of complications, such as air leaks. One study revealed that aerosolized ICG could be used to increase the intra-operative detection of air leaks from 75% to 98% (P=0.001) (79). Another clinical trial of 288 patients that used similar ICG techniques to detect air leaks in one group compared to standard white light techniques in the control group revealed that ICG allowed for the intra-operative detection and treatment of air leaks via suture or stapling leading to a significantly lower rate of post-operative air leaks in the ICG group (20.8% vs. 37.0%, P=0.01) (80). Similar case series have shown success in everyday clinical practice (81). Therefore, aerosolized ICG may pose an important tool for detection of air leaks after lung resection to prevent post-operative complications that may lead to longer hospital stays and increased healthcare costs.

Anomalous anatomy and blood supply

There are countless other unique uses for ICG in the pulmonary setting. For example, anomalous arterial anatomy is relatively common, and fluorescence imaging can help identify this anatomy intra-operatively to assist in the completion of a safe operation (82-86). It can also be used to identify boundaries when incomplete fissures exist or significant scarring is present from prior surgeries, similar to those previously described for segmentectomy (87-91). Additionally, pulmonary sequestration can often be difficult to localize, so ICG can either be inhaled, injected into the airway, or used intravenously after embolization of the associated artery to accurately identify the affected portion of lung (92-98). One multicenter study showed that using inhaled ICG to identify pulmonary sequestration led to shorter post-operative recovery time, shorter chest tube duration, and improved lung function post-operatively (99).

Finally, ICG can be used to determine viability and blood supply of bronchial stumps during bronchoplasty (100,101). This can help reduce post-operative complications, such as dehiscence or bronchopleural fistulas. If bronchopleural fistulas do arise, ICG can be used to ensure that flap coverage only involves healthy, well-vascularized tissue (102,103).

Uses in esophageal surgery

Assessment of anatomy and perfusion

Fluorescence imaging has several uses in esophageal surgery as well. The first major use is for identification of vessels and tissue perfusion. This can be done to identify normal or aberrant anatomy and conduit perfusion. In an RCT, use of ICG for evaluation of gastric conduit anastomoses were compared to those assessed solely based on surgeon experience and found that anastomotic leakage was significantly lower in the ICG group (6.7% vs. 21.3%, P=0.02) (104). Another trial of 109 patients undergoing esophagectomy revealed that lower ICG velocities (<2.07 cm/s) in the gastric wall were associated with higher anastomotic leakage rates (P<0.001) (105). Others have used similar techniques in technically challenging cases and alternate conduits (106,107). Reducing anastomotic dehiscence after esophagectomy is vital in reducing post-operative morbidity and mortality.

Lymph node mapping

During esophagectomy, ICG can also be used for lymph node localization or lymphadenectomy. In this area, studies have shown more promise than of studies previously mentioned for lung cancer nodal dissections. One comparative effectiveness study assessing differences between lymph node yields between NIF-guided mediastinal lymphadenectomy to conventional lymphadenectomy during esophagectomy showed that the fluorescence group gathered significantly more lymph nodes overall and more mediastinal lymph nodes (108). An RCT that used injections of ICG into peritumoral spaces similarly showed higher lymph node yields in the ICG group compared to a control group that did not receive ICG for nodal identification during esophagectomy (109). Interestingly, in the ICG group, any lymph nodes that came back positive for nodal disease also lit up with ICG fluorescence and all lymph nodes that did not illuminate, but were still removed, were negative for malignancy. This showed clear advantages to the use of ICG for lymph node localization in esophagectomy as it not only helped identify nodes, but it also appeared to highlight the most critical lymph nodes for removal. Other studies have similarly demonstrated lymphatic drainage patterns unique to patients and nodal positivity associated with those that take up ICG, so ICG-guided lymph node mapping appears to be particularly useful in esophageal cancer resections (21,110). It’s possible that ICG could allow for more targeted lymph node dissections in the future if further studies corroborate these findings.

Identification and avoidance of injuries to bronchi and thoracic duct (TD)

Another factor to consider during esophagectomy is avoidance of damage to surrounding structures. For example, bronchial injury is a rare but serious complication during esophagectomy. Endobronchial injection/aerosolization of ICG prior to esophagectomy can allow for marking and identification of bronchi intra-operatively for better delineation of structures and a safer dissection. In fact, one study showed successful identification of bronchi in 95% of cases using this technique (111).

ICG has also been used to identify the TD during esophagectomy and identify intra-operative injuries in real-time, thus allowing for expeditious repair of chyle leaks. Injection can be done via multiple routes, but the most common are mesenteric injection or inguinal injections prior to surgery (112-114). During one study, fluorescence allowed the detection of TD injuries in three separate patients which led to rapid TD ligations during the same operation and no post-operative chyle leaks (113). Numerous reports have also detailed various experiences with TD localization, injury identification, and subsequent ligation with the assistance of fluorescence imaging. Many of these cases involved esophagectomy, but others also involved thoracoabdominal aneurysm repair, pneumonectomy, lymphangioleiomyomatosis, post-traumatic injuries, and idiopathic causes (115-123). Therefore, there are many different techniques to using ICG in this setting, whether prophylactically to identify structures or to diagnose and treat injured lymphatics. Regardless, ICG has countless uses within esophageal surgery both for intra-operative and post-operative management.

Endoscopic esophageal marking

Similar techniques may be used endoscopically for benign esophageal surgery as well. For example, the core management in many cases of esophageal diverticula is a complete resection. One group endoscopically injected ICG into the mucosa of the neck of an esophageal diverticulum to clearly identify the base of the structure, improve visibility and precision, and ensure complete resection of the pathology (124).

Uses in mediastinal surgery

The mediastinum is another complex space full of critical vascular and airway structures, which require careful navigation by skilled surgeons. Unsurprisingly, fluorescence-guidance in this space has proven useful in multiple reports. Multiple different types of tumors can arise in this area, including primary mediastinal tumors and ectopic tissue or metastatic disease. For example, parathyroid adenomas are commonly found within the mediastinum. In these cases, Sestamibi scans are useful pre-operative studies to localize the masses, however clear delineation of the pathologic gland from surrounding tissue planes intra-operatively is not feasible with this modality. Parathyroid adenomas can take up ICG in approximately 93% of cases (125). Therefore, intraoperative fluorescence can be a useful adjunct to help surgeons localize these small ectopic glands, providing a safe and accurate route for localization and resection (126).

ICG-guidance has also been used during other mediastinal tumor resections, such as thymomas or giant mediastinal tumors encompassing great vessels (127,128). In one case, surgeons used the second near-infrared window (1,000–1,700 nm), which permitted exploration of deeper tissue and afforded a higher resolution compared to traditional near-infrared windows of 700–900 nm (127). In this case, ICG allowed effective angiography of a giant anterosuperior mediastinal tumor and its associated complex vascular structures, showing clear benefits to reducing vascular injury and increasing operative safety. Other groups have used similar techniques to identify and preserve the phrenic nerve in large mediastinal tumor dissections (129). One study of 25 patients with anterior mediastinal tumors found that ICG identified two patients with residual disease and allowed for dissection away from the phrenic nerve in four cases that otherwise would not have been feasible (130). Therefore, it’s clear that fluorescence imaging has multiple uses in mediastinal surgery and may even be underutilized in this complex and tight space.

Chest wall, diaphragm, and other uses

Other creative and unique uses have been found and reported in the literature, which are also important to highlight. For example, diaphragmatic injuries or defects can arise from multiple sources and can often be difficult to localize and repair. One case in the literature revealed hepatic ascites leaking into the chest through a diaphragmatic defect. ICG was instilled into the peritoneal cavity and used to localize the site of the defect, leading to proper repair and prevention of further pleural effusions (131). Another group reported three similar cases of diaphragmatic defects leading to peritoneal dialysate leaking into the chest. The patients’ dialysis solutions were “colored” using ICG, allowing for direct localization and repair of the defects (132). These techniques support more durable results compared to repairs without this imaging modality as cases of pleuroperitoneal communication often have high recurrence rates due to small or missed diaphragmatic defects.

Another group incidentally found that ICG can identify sympathetic ganglions, which may be useful in sympathectomy for hyperhidrosis (133). One study of 142 patients injected with intravenous ICG led to successful fluorescence-guided identification of sympathetic ganglions in 96.7% of cases (134). This may be particularly useful in patients with increased scar tissue or difficult anatomy that make the sympathetic chain difficult to visualize. Therefore, new uses of ICG and fluorescence imaging are constantly being discovered and it’s likely that its potential has not been fully realized.

Limitations and future directions

Although we have primarily highlighted the benefits and uses thus far, it is also important for thoracic surgeons to understand the current limitations of the technology and existing literature. For one, the current literature is full of case reports and case series demonstrating the successful use of ICG in thoracic surgery. However, randomized trials comparing its use to surgeon experience, other localization techniques, or newer augmented reality platforms are limited. Most of the human clinical trials available have shown excellent results. However, some failed to show distinct differences in long-term outcomes, which is important to consider. For example, lymph node yields appear to be higher with ICG, but in one clinical trial this did not affect other outcomes, such as overall survival (108). Additionally, in the case of lymph node harvesting, some studies suggest that neoadjuvant therapy or positive lymph nodes could limit the effectiveness of ICG infiltration, so this may require further study to clearly define which patients are candidates for ICG-guided lymphadenectomy and determine how much surgeons can rely on these imaging modalities (135).

There may also be other factors at play for use in the detection of lung nodules. For example, some studies suggest that ICG is less effective in emphysematous lungs as these typically have poor blood flow, so certain areas will not take up fluorescent dyes when given intravenously (58,136). This is a situation where more directed dyes, such as pafolacianine, may be needed and increasingly utilized in the future. Ultimately, determining the specific factors that lead to success or inability to use fluorescence in certain patients or conditions will be vital moving forward. Furthermore, we previously described some differences in success based on route of administration, so tailoring these practices will also be required.

Although ICG is relatively safe with adverse effects in less than 1% of patients, severe reactions, such as anaphylaxis can occur (17). This is especially true at higher doses, which are sometimes required in certain applications, such as those needed with intravenous use or staining of pulmonary nodules. The timing of injection can also be a limitation. There is large variation depending on the route of administration and patient-specific factors. For example, lymphatic injections often take time to spread to the appropriate lymph nodes, and this staining may only last a couple hours; meanwhile pulmonary injections can last days (137-139). Therefore, timing and route of administration may require further study to identify factors that contribute to intensity of fluorescence and optimal intra-operative imaging based on what structure is being targeted. It is vital that we continue to study and create best practices to minimize repeat injections, excessive dosages, and reduce healthcare costs.

Additionally, there are some inherent limitations to existing dyes, such as ICG. For one, deeper nodules (typically >2 cm from the surface) are often difficult to identify with ICG. It’s likely that development of other dyes or imaging modalities will be needed to address this limitation, such as the aforementioned Cetuximab-IRDye800CW which provides deeper penetrance (60,140). Furthermore, we have highlighted multiple uses of ICG during the same operation, for example during esophagectomy where it can be used for bronchial identification, lymphatic identification, and perfusion of the gastric conduit. However, the dye only works at a specific wavelength meaning it currently can only delineate one structure at a time. To adequately identify multiple different structures at the same time, we would need to inject separate-colored dyes that work at different wavelengths into these different structures. It’s possible that in the future three-dimensional (3D) reconstruction techniques could augment this process. For example, there has been a significant rise in virtual and augmented reality platforms over recent years that can create overlays onto the patients (141). These platforms have the potential to eventually assist with lesion localization or structure identification; however, it is currently still being developed, and at the present time, ICG remains a simple, reliable and effective method for localization, anatomical identification, and treatment of structural injuries during thoracic surgery.

Conclusions

The thoracic cavity presents unique challenges for surgeons given countless critical structures, aberrant anatomy, unique complications, and an ever-changing landscape of minimally invasive surgery. Within this space, fluorescence imaging techniques shine to show surgeons the path toward a safe operation whether it involves lung lesions, airways, structures of the nervous system, lymphatics or mediastinum. Fluorescence imaging allows for direct localization or identification of many lesions and structures with some newer fluorescence technology potentially allowing for use in deeper tissues and more targeted applications. With the assistance of fluorescence techniques, thoracic surgeons may provide safer operations for patients, while identifying and treating complications in real time.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-2026-1-0004/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-2026-1-0004/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-2026-1-0004/coif). Z.M.A. serves as an unpaid editorial board member of Video-Assisted Thoracic Surgery from September 2025 to August 2027. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Written informed consent was taken from all the patients for images used in the manuscript.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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