AB209. SOH26AB_0277b. Case report of laparoscopic management of small bowel ischaemia from closed loop obstruction: the role of indocyanine green fluorescence in avoiding bowel resection

Background: Assessment of small bowel viability in closed-loop obstruction is challenging, and intraoperative decisions are often based on subjective visual cues. Indocyanine green (ICG) fluorescence angiography provides objective real-time perfusion assessment but is not routinely used in emergency laparoscopic surgery. We present a case where ICG directly changed operative management and prevented unnecessary bowel resection.

Case Description: A 74-year-old man with significant comorbidities—atrial fibrillation on dabigatran, ischaemic heart disease, mitral regurgitation, type 2 diabetes, hypertension, and prior umbilical hernia repair—presented with 24 hours of abdominal pain, vomiting, and distension. He was tachycardic with rising lactate (4.1 → 4.7 mmol/L), leukocytosis (26.3×10⁹/L), and acute kidney injury. Computed tomography (CT) demonstrated a high-grade closed-loop small bowel obstruction in the left upper quadrant with long-segment mural thickening and mesenteric stranding concerning for ischaemia. The patient underwent urgent laparoscopic adhesiolysis. A tight band adhesion created a closed-loop segment. Approximately 30 cm of small bowel appeared dusky, oedematous, and poorly contractile despite observation. Resection was considered. ICG fluorescence angiography (3 mL) demonstrated immediate perfusion throughout the questionable segment, confirming viability. Resection was therefore avoided. The patient required short-term postoperative vasopressor support but recovered well, tolerating diet by postoperative day 2 and discharging home on day 5.

Conclusions: ICG fluorescence provided objective confirmation of bowel viability and altered operative decision-making, preventing unnecessary resection. This case highlights the value of ICG as a decision-support tool in emergency laparoscopic surgery for suspected ischaemic obstruction.

Keywords: Bowel viability assessment; closed-loop obstruction; indocyanine green fluorescence (ICG fluorescence); small bowel ischaemia; case report