166 Chapter 8 all modalities, LSCI could emerge as a more direct, real-time, and repeatable approach in providing quantitative information on tissue perfusion 28, 40, 42-45. Strengths and limitations This study maintained standardized conditions 20, 46. The laparoscope was set at a perpendicular position at 14 cm to tissue to mitigate the effects of camera angulation and laser intensity 13. PerfusiX-Imaging® utilized algorithms to compensate for motion-induced pixel contrast variations 47. However, caution is advised in interpreting the findings, and further human investigation is required to assess reproducibility in clinical settings. The device is currently limited to research applications and the intraprocedural LSPU graph presentation is developed specifically for this study. While most of the elective abdominal clinical procedures involve laparoscopic approaches, the bowel loops were created during laparotomy and the laparoscopic system was used in an open setting to maximize standardization (and minimize the procedural time). Nonetheless, a prior technical demonstration has affirmed that the camera system was working appropriately in a total laparoscopic setting 18. This study specifically addresses ischemia of the small intestine instead of colon surgery, which is more prevalent in daily clinical practice, acknowledging the impracticality of generating ischemic bowel loops in the porcine colon due to its spiral-like orientation 12. Additionally, colorectal resection in a human population is often complicated by a higher presence of visceral fat compared to a porcine model. Nevertheless, prior studies have demonstrated favorable outcomes utilizing the same device for assessing colonic perfusion in human subjects 16. Despite the modest sample size, we considered it adequate to address our hypothesis while adhering to the principles of the 3R framework (replace, reduce, refine) in animal research 48. However, this precluded examination of inter-animal differences from the mixed model analysis. A larger-scale study could offer insights into variations in baseline perfusion and enhance understanding of cut-off values and LSCI quantification. The next phase would be to further quantify measurements to precisely identify (non-) viable tissue and safe resection zones. Interpreting subtle perfusion differences is crucial for assessing tissue viability, particularly when ischemia is not evidently clear or when achieving this necessitates a profound comprehension of perfusion variations within tissues and across patients, emphasizing the importance of continued studies on the quantification of LSCI. Furthermore, future research should focus on evaluating LSCI in clinical trials to assess its impact on surgical outcomes, including AL rates, and compare its effectiveness with conventional white light imaging.
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