Indocyanine Green Fluorescence During Heller Dor Myotomy for Achalasia: Techniques, Intraoperative Applications, and Evidence Gaps—A Scoping Review

Background: Heller myotomy (HM) is the standard surgical treatment for achalasia. Complete muscular division while preserving mucosal integrity is essential for optimal outcomes. Indocyanine green fluorescence (ICG) imaging has recently emerged as a potential intraoperative adjunct during minimally invasive HM, although evidence remains limited and heterogeneous. Methods: A scoping review was conducted according to PRISMA-ScR recommendations. PubMed, Scopus, and Web of Science were systematically searched to identify clinical studies reporting intraoperative ICG use during laparoscopic or robotic HM. Data regarding surgical approach, fluorescence technique, intraoperative applications, and outcomes were extracted and descriptively synthesized. Results: Four clinical studies published between 2022 and 2024 were included, involving 58 patients overall, of whom 41 underwent minimally invasive HM with intraoperative ICG fluorescence assessment. Two main fluorescence strategies were identified. Intravenous ICG administration was exclusively evaluated during robotic Heller myotomy, whereas all laparoscopic studies employed intraluminal ICG instillation through a nasogastric tube. Fluorescence imaging was used to assess myotomy completeness, identify residual muscle fibers, and detect mucosal perforation. Intraluminal ICG enabled direct visualization of the mucosal tube and facilitated leak detection, whereas intravenous administration enhanced tissue contrast and identification of residual muscular bundles. No ICG-related adverse events were reported. However, the available evidence was limited to small observational series with heterogeneous protocols and inconsistent outcome reporting. Conclusions: ICG fluorescence appears technically feasible during minimally invasive HM and may support intraoperative assessment of myotomy completeness and mucosal integrity. Although early clinical experience is encouraging, the available evidence remains insufficient to support routine implementation of ICG-guided assessment during Heller myotomy, highlighting the need for standardized prospective comparative studies.