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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
\n\nThis achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
\n\nWe are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
\n\nThank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
\n\n\n\n\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"2759",leadTitle:null,fullTitle:"Science and Technology of Casting Processes",title:"Science and Technology of Casting Processes",subtitle:null,reviewType:"peer-reviewed",abstract:"This book deals with various science and technology factors that need careful consideration in producing a casting. 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Knowledge management (KM) has been recognized as an imperative element for leveraging organizational effectiveness and performance. Organizations practicing effective KM methods achieve positive results in their organizational competitiveness, particularly innovation and creativity [1–3]. Despite the positive effects of KM, research on the KM pillars remains diverse. This study examines the interplay of the three major KM pillars acting as the platform for effective KM instigation.
On the basis of interviews with KM‐intensive organizations, their good practices were categorized through a thematic analysis. Thereafter, an exploratory quantitative study from a sample of 44 respondents in different organizations was conducted to examine the relationship of the three major KM pillars. The survey results were further examined to evaluate the effects on organizational performance. Organizations harnessing a hybrid strategy to balance deployment of people, process, and technology gain positive results in their performance. The findings can provide direction for future studies to facilitate management in the deployment and integration of the KM pillars for attaining desirable organizational outcomes.
To understand effective KM practices, interviews were conducted with the senior management from two locally renowned KM‐intensive organizations; the interviewees serve as key informants who steer and propagate KM. The qualitative data from these organizations were analyzed and thematized into three essential KM pillars, namely, people, process, and technology, which constitute organizational performance (Figure 1) [4–7].
Three knowledge management pillars.
KM is embedded in working processes and practiced by each individual at different organizational levels, spanning from the senior‐most to junior‐most personnel. Typically, top managers champion the instigation of KM programs, provide vision to align the organizational strategy with the KM programs, and oversee the diffusion of KM initiatives throughout their organizations [8]. Members at different organizational levels act as knowledge workers who harness and utilize the knowledge assets residing in their cognitive repositories [9]. Through collective inquiry, sharing, and assimilation of knowledge, innovations and desirable organizational outcomes are boosted [1, 10]. Therefore, people are considered the heart of leveraging and creating knowledge for organizational competitiveness. Their cognitive minds influence their approach to the processes of accommodating, validating, and creating different ideas solicited from different sources.
Using communication and collaboration technologies to support knowledge management is ubiquitous. Its effect is universally discussed as an indispensable means to facilitate the acquiring, codifying, indexing, updating, and disseminating of knowledge among employees [10–12]. Organizations invest in KM technology, such as document management systems and yellow pages, which enables the presentation of captured knowledge in readily available forms for different users.
Equipped with collaborative‐oriented KM technology, employees can connect to one another within (e.g., through organization‐specific intranets) and outside organizations (e.g., through the Internet) for rapid knowledge flows with enhanced time value. Employees using KM system (KMS) with learning and creation intention aim to capitalize knowledge assets through social networking and collective inquiries [12, 13]. With trust and reciprocity of exchange, employees share resembling identity over communities of practices to explore or exploit more new ideas and collaboration. User‐oriented KM systems (KMS) supports, such as training workshops and forums, may further assist the adoption of KM processes in daily operations.
Knowledge is mostly characterized by its tacit and intricate nature, and it resides in the mind of individuals [14–17]. Through individual inquiry and exploration, knowledge is activated from one’s repository and externalized in different formats. By engaging through group dialogue, interaction, and exchange, knowledge can be pooled from different sources and created into different explicit stances. KM processes can generally be defined as an array of designated practices facilitating the flow and added value of knowledge. These processes not only help organizations identify and acquire knowledge from multiple sources but also allow their employees to explicate and disseminate knowledge in comprehensible formats. Valuable knowledge, skills, and competencies are documented and stored in knowledge repositories assuming various forms (e.g., minds of employees). Structured and planned documentations enable employees to share and retrieve relevant knowledge for implementing associated tasks. Employees can also assimilate new knowledge input to reconfigure existing knowledge and create new ideas for enhancing organizational goals [18, 19].
A central tenet of harmonizing the three KM pillars is their association with organizational performance. Prior research indicates that effective human resources deployment, such as organizing employees to work as a team to leverage collective expertise, can be conducive to innovative activities [13, 20]. Management should also integrate KM processes allowing employees to harness, access, share, use, and create knowledge at different stances [21]. Equipped with KM technology, employees can leverage personal knowledge and improve skills through sharing and collaborative learning [9].
In this study, management who can utilize knowledge can leverage their capabilities to improve business profitability, streamline working processes, and influence coordination of efforts as well as responsiveness to market‐changing innovation [16, 18, 22], thus contributing to desirable organizational performance.
Prior study explained that although most companies find KM promising, they can only capitalize on a few processes [19]. They further asserted that action is vital to turn knowledge into practice, which, in turn, allows knowledge workers to learn from mistakes and move on to the next stage. As an exploratory examination, the current study focuses on the practice of the three KM pillars in organizations. The relative importance and hierarchical position of the three KM pillars are then examined. The perceived importance of KM pillar is construed to influence the way management steers the KM program. Accordingly, the congruence between perception and the KM orientation is investigated. Given the different KM strategies and mix of the KM pillars, organizational performance is expected to vary. The notions are illustrated in Figure 2.
Framework of perceived importance, practice, and performance.
This exploratory study employed questionnaire‐based survey for data collection. Pilot tests with one professor and one business practitioner were conducted in order to solicit feedback on the structure, readability, and completeness of the questionnaire. In 2013, the revised questionnaires were distributed to 93 study informants, with a cover letter to depict the major objective of the study. To improve the understanding of information from respondents with conception and experience of KM, study informants who engage, steer, or participate in organizational KM were primarily solicited to participate in the survey. The data collection period lasted about 5 months, with 44 valid questionnaires were returned for analysis.
In order to minimize the social desirability bias, anonymity was stated explicitly to all study informants in the cover letter. The study mainly examined the constructs of perceived importance of the KM pillars, practice of KM pillars, and organizational performance. To assess the interplay of the three pillars and their effects on organizational performance, the study also conducted tests of the correlations of the three pillars with the organizational performance. Each pillar was measured with multiple questions. Except for questions regarding the demographic background of respondents and the company information, all questions adopted a five‐point Likert scale (Table 1).
Characteristics | Number of respondents | Percentage of respondents |
---|---|---|
Male | 29 | 65.91 |
Female | 15 | 34.09 |
Under 25 | 2 | 4.54 |
25–34 | 10 | 22.73 |
35–44 | 30 | 68.19 |
45–54 | 2 | 4.54 |
Banking and insurance | 6 | 13.63 |
Engineering | 10 | 22.73 |
IT and telecommunication | 10 | 22.73 |
Manufacturing | 5 | 11.36 |
Wholesale, retail, export, and import | 13 | 29.55 |
Profile of respondents.
To assess the interrelationships among the three KM pillars, descriptive statistics and correlation coefficients were derived with the aid of Statistical Package for the Social Sciences (SPSS). The perceptions of respondents were also examined to evaluate whether the three pillars influence how they harness knowledge assets.
All 44 respondents expressed a unanimous agreement toward the importance of the three KM pillars, namely, people, technology, and process, to organizational growth. The awareness and recognition toward the three pillars are presumed to influence the KM agenda and endeavors in their organizations.
Upon their consensus, the respondents were asked to rank the order of the three pillars in their organizations according to importance. Two diverse views were identified from the respondents: (1) the three pillars are conceived as equally important and (2) a specific KM pillar is more crucial than the other two KM pillars. In Figure 3, nearly half of the respondents (45.4%, 20) explicated that people, process, and technology are inseparable and valued equally significant in their organizations. The rest of the respondents (54.6%, 24) perceived their organizations to have dissimilar emphasis over the three KM pillars. This dissimilarity accounted for the diversity in their organizational profile, history, competitive edges, and environment.
Perception of the most important knowledge management pillar.
The 24 respondents were further asked to reflect their views toward the most important and rudimentary pillar in their organization and rank the three pillars accordingly (from the most to the least important pillar). The result is illustrated in Figure 4; 11 respondents (25.0%) perceived “people” as the most important pillar, followed by eight respondents (18.2%) for “technology,” and finally five respondents (11.4%) for “process.”
Perceived importance and inclination of knowledge management pillars.
Apart from the ranking order of KM pillars, the 24 respondents were asked to reveal their perception toward the degree of importance of the KM pillars. The study employed a 5‐point Likert scale (ranging from 5 = most important to 1 = least important) and computed the mean scores accordingly. The higher the mean, the higher the perceived importance of the particular pillar toward the organizational performance. Among the three KM pillars, “people” was rated with a mean score of 4.19, which was higher than “technology” and “process” pillars with respective scores of 3.88 and 3.71.
Emanating from theory of action advocated by Argyris and Donald [23], individuals are encompassed with a disparity between their “espoused” theory and theory in use. For example, participants in community of practice clearly know the benefits of knowledge sharing. However, in practice, employees may not explicate or externalize their knowledge continually because of different private agendas held or reciprocity toward community members. A similar assertion is found in the current study. Despite the slight disparity, the perceived importance of KM pillars communicated to others is realized to be only partially congruent to the respective KM pillar deployment. To illustrate this point, all 44 respondents were further asked to evaluate the inclination of their KM strategy. The findings (Figure 4) presented four major KM strategies adopted in the organizations, namely, hybrid, people‐oriented, technology‐oriented, and process‐oriented [24, 25].
In connection with the previous finding, 18 of the 20 respondents revealing the equal importance of the three KM pillars asserted that a “hybrid” strategy of KM practice is deployed in their organizations. Their KM plans incorporated and assimilated the three KM pillars to leverage people to engage in various KM processes, with the aid of KM‐related technology to drive innovation and organizational improvement. They emphasized the interdependence and indispensability of people, process, and technology enabling organizational members to explore and exploit different types of knowledge.
Likewise, 10 of 11 respondents discerning “people” as the most important KM pillar, asserted that people‐oriented KM strategy is carried out in their organizations. They emphasized that sources of innovation and new ideas are primarily instigated from people, given that most of the knowledge are tacit in nature and deeply residing in the mind of individuals. The organizations deploy diverse groups of KM people to articulate, interpret, and share knowledge among one another.
Concerning the supremacy of the ubiquitous technology in organizations, 11 respondents asserted that the technology‐oriented strategy is adopted in their organizations, whereas only 8 respondents conceived “technology” as the most important pillar in the previous session. The 11 respondents explained that technology is extensively used in their workplace to connect, communicate, and collaborate with parties in and outside the organization. Technology facilitates the integrative (e.g., new and old knowledge combination) and interactive flow (e.g., different knowledge workers exchange knowledge) of knowledge assets.
The five respondents valuing “process” pillar mostly concurred that KM strategies are primarily process oriented. The process‐oriented strategy is characterized as a deliberated series of KM activities, including acquiring, storing, retrieving, reusing, applying, and creating knowledge, sequentially integrating with other organizational operations through the knowledge workers or technology‐enhanced platforms.
Other than the congruence of the KM perception and KM strategy, understanding the effectiveness of their KM practices is important to evaluate organizational performance. The general results of organizational performance presented in Table 2 showed that organizations adopting a “hybrid” strategy attained better scores than those organizations adopting KM strategies driven by a particular KM pillar. The 18 organizations demonstrated and experienced the highest organizational performance (mean = 4.32); the three KM pillars were well‐adjusted and developed, resulting in moderately high scores of 4.28, 4.08, and 4.11 for people, technology, and process, respectively.
Strategy | |||||
---|---|---|---|---|---|
Hybrid | People | Technology | Process | ||
People | 4.28 | 3.87 | 2.33 | 3.40 | |
Technology | 4.08 | 2.90 | 4.36 | 3.40 | |
Process | 4.11 | 2.97 | 3.12 | 4.00 | |
Organizational performance | 4.32 | 3.47 | 3.06 | 3.40 |
Correlation between knowledge management pillars and knowledge management strategy.
Organizations with KM inclinations showed interesting findings with regard to KM effectiveness. The results from people‐oriented organizations revealed that the pillar of people performed the best with the mean score of 3.87, followed by process and technology with mean scores of 2.97 and 2.90, respectively. Technology‐oriented organizations deployed efforts and realized highest effectiveness in the pillar of technology when compared with the results of other two pillars (technology = 4.36, process = 3.12, people = 2.33). The KM effectiveness of process‐ and people‐oriented organizations demonstrated a similar pattern. In process‐oriented organizations, the most effective KM pillar is process (mean = 4.0), followed by people and technology, which shared the same mean value of 3.40.
Recognizing the organizational performance of other non‐hybrid organizations with less favorable results is necessary (Figures 5–7): people‐oriented, process‐oriented, and technology‐oriented organizations obtained a mean of 3.47, 3.4, and 3.06, respectively. Although the inclination toward a particular KM pillar enables organizations to exploit their KM resources, the inattentive practice or under‐utilization of other KM pillars may hinder their long‐term growth in today’s dynamic environment. Given the intricate nature of knowledge process, high mobility of the knowledge workers and swift change in advanced technology as well as support and championship from management are paramount for encouraging organizational members to explore the current knowledge sources in organizations or to acquire the pillars externally (e.g., recruitment of quality staff).
Organizational performance by hybrid strategy and people‐oriented strategy.
Organizational performance by hybrid strategy and technology‐oriented strategy.
Organizational performance by hybrid strategy and process‐oriented strategy.
The descriptive statistical results indicated that the gap between espoused theory (regarding their perceived importance) and theory in use (regarding the inclination practice) was further evaluated. Figure 8 illustrates the correlation coefficients of the three major pillars. The perceived importance of KM pillars showed a relatively strong relationship with the KM practice (0.80). Most of the organizations are consistent with what they believe and communicate to others in regard to their KM strategies. No obvious disparity exists between their degree of championing KM and the degree they engage in KM. Similarly, the results demonstrated a strong relationship between the KM practice and organizational performance, with a correlation coefficient of 0.87. The KM strategy steered by management is important in promoting the synergistic coordination of different organizational resources to achieve desirable organizational results.
Correlation of perceived importance, practice, and organizational performance.
The preliminary findings reveal that management and employees have variable perceptions toward the relative importance of the three KM pillars. Their inclined perceptions influence the degree of KM pillar being practiced and exploited in KM programs. The current study also shows that organizations propagating hybrid KM strategy result in relatively higher effectiveness in organizational performance than those non‐hybrid organizations do. The skewed emphasis on a particular KM pillar, such as technology orientation, seems like a one‐legged chair that is rigidly stacked at a particular point.
Given the dynamic change of business environment, organizations not only have to maximize the effectiveness of organizational routines but also harness changes and develop new competitive strengths. The findings from current study encourage joint efforts from management and employees to configure a hybrid KM strategy, that is beyond the two‐dimensional classification of KM strategies, either personalization or codification [26, 27]. The following section provides recommendation to management for courses of action to explore more on KM pillars that may be least attended or emphasized in current stage, ultimately to attain a desirable organizational performance.
The attitude of the top management toward KM serves as an explicit gauge for an organization‐wide KM activity. Steered by the top management, a KM task force can be created to symbolize their dedication and enthusiasm toward their employees [8]. The key values and affirmative perception toward KM, such as knowledge is a fluid and growing asset; knowledge is not confined as personal power; and knowledge is best valued if it is shared, can be cultivated, and institutionalized to all employees. The vision to embody the significance of KM can attract additional dedication from employees when KM initiative is in its infant stage.
Centered as the frontrunner in KM community, the top management can stretch KM boundary and embody the KM significance to different departments. They can identify early adopters with enthusiasm for KM processes and involve them in propagating the KM vision through connections and interactions. Thereafter, the community can be further extended to diverse work groups/departments and encourage members to bring in a constructive disruption toward the status quo and stimulate other new ideas. The bond among people can be strengthened through the participation of knowledge workers characterized by different roles (e.g., novice, regulars, and experts) in the community. Regular meetings to exchange ideas or articulate competent skills to members are beneficial to peer learning.
Within the community, KM activists, including the top management and employees, can advance the KM perception as a spiritual KM culture. Fostering a knowledge‐friendly culture with unwritten norms and beliefs is crucial because turning KM visible to all organizational members requires time. Organizations can encourage people to experiment with different ideas to develop a new working process that is in parallel with their autonomy in task. Such working atmosphere can facilitate open communication channels and knowledge‐sharing sessions at both formal and informal setups, such as conducting a bimonthly good work practice sharing allowing employees at all levels to explicate or solicit feedback of their work practices.
KM processes involve both formal and informal dynamics, ranging from casual conversations in the hallway to socialization regarding work processes over departmental meals to pre‐arranged, focused discussion sessions held in meeting rooms. Organizations can devote extra efforts to engage major processes, including acquisition and capture, conversion and organization, storage and dissemination as well as creation and usage [27]. Further actions are required to interweave the KM processes holistically because such knowledge assets can be an added value to facilitate informed decision making and strategy.
Knowledge is intricate with its multiple facets [1, 2, 28]. Management must identify its paucity and presence at individual, group, and organization contexts. Therefore, employees are encouraged to tap in diverse sources, acquire the critical knowledge, such as core competencies and know‐how residing in a particular employee’s mind, or capture the knowledge embedded within a particular organization process, or deduce good practices adopted from outside organizations.
Efficiently and effectively conversing and organizing knowledge into the appropriate format for easy access and retrieval are crucial in the organizational KM agenda. Explicit knowledge, such as text‐based reports and procedural manuals, is relatively communicable to others. Thus, experts can explicate their knowledge and codify them in a structured form. By contrast, tacit knowledge, such as capability to understand and to read the cues from customers’ propensity to purchase, cannot be verbalized and articulated entirely to others. Organizations may have to devote extra resources to convert them into demonstrative video or narrative good practices that can be learned by knowledge seekers through a different mode.
Sharing is one of the most challenging processes if knowledge is confined as a personal asset rather than a social capital in the organization. Equipped with a sound incentive system (covering both monetary and non‐monetary recognition), the infant KM stage may progress with a mandatory sharing from experts or experienced staff. During the growth stage of the KM program, sharing exercise can be regularly conducted with the active participation from the top management. Further sharing can be boosted on a voluntary basis, with many employees sharing and exchanging their good practices reciprocally through an informal setup, such as social conversation, or through a formal route, such as documented publications [28].
Knowledge creation is occasionally a spontaneous process, where innovative ideas are not confined to the domain expertise or experienced colleagues. It can also be an emergence of a novel idea or one that adds value to reconfigure a current idea or enhance working practices, which, in turn, can be applied in new contexts. Management can encourage employees to explore their ideas playfully through trial‐and‐errors for invention. Furthermore, management can provide extra “time” resources to support creation, such as releasing employees from work to cross‐fertilize ideas with colleagues from different disciplines.
In some organizations, knowledge management is closely associated with sophisticated systems, enormous database, and advanced infrastructure. Management must realize that the presence of KMS offers no guarantee that the users will automatically come nor hoard knowledge and skills from the repositories. KMS is capitalized as an effective and useful conduit when users interact, learn, and collaborate with others and harness reusable knowledge for their own work situations and processes [18, 29].
The perceptions held by the KMS users affect the extent of system usage, such as perceived ease of use and usefulness. Therefore, management can designate the IT staff for involving end users to participate in the KMS design and development process. The genuine needs in knowledge representation, expectation of feature‐rich interface, and potential problems in the evolving knowledge repositories can be directly solicited. The involvement from end users reinforces the commitment and satisfaction when the system is launched because KMS is developed “for” them.
Undoubtedly, KMS enables organizations to be more agile and fluid because skills, competencies, and ideas can be stored, accessed, retrieved, and disseminated to the right people, at the right time, and at the right place [11, 12]. It presumably connects employees on a potentially fruitful platform that enables them to access, integrate, and generate knowledge. Therefore, management must be cautious to avoid putting excessive efforts in preserving and storing knowledge assets as stock in the repositories. Employees are encouraged to keep knowledge “alive” through a continuous review, updating, disposal, and sharing. Regular evaluations of system effectiveness, such as portal design and relevance of knowledge content for decision making are required.
This study is an exploratory attempt to examine the KM pillars and impacts on organizational performance. Further studies should be conducted to overcome the limitations of the present study. First, the findings were drawn from individual study informants who engage in their organizational KM programs. Using the samples from multiple respondents of a work unit may shed new insights in KM, such as the degree of unanimity on KM pillars moderated by culture, private agenda, or work commitment. Second, the future research can collect more samples to generate additional statistical power and allow added robustness to the model testing. Third, in‐depth examination of the hybrid strategy could be conducted to enable organizations to obtain a clear picture of their KM status. For example, future activity can be extended to the behavioral traits of knowledge workers, impact of different KM processes on sustaining competitive advantages, and complementary and substitutability roles of IT in KM process.
Knowledge management has become one of the most important activities across different organizations. Management is struggling with the efforts to embark on KM initiatives and the minimal return in competitiveness. This exploratory study identified three KM pillars acting as fundamental constituents driving KM programs to attain a desirable organizational performance. The findings showed that organizations perceived the KM pillars differently, which influence their practices to implement KM strategy. The orientation toward different KM pillars resulted in varying effectiveness of organizational performance. Adapting a hybrid strategy is concluded to yield better results. Accordingly, actions are recommended to enable organizations to re‐examine their current status and adopt changes for balanced KM programs.
The work described in this chapter was substantially supported by a grant from the College of Professional and Continuing Education, an affiliate of The Hong Kong Polytechnic University.
As the general surgical techniques have polished with more and more precise gestures, which in time lead to the appearance and development of even robotic surgery, the same phenomenon happened when it comes to adjuvant methods to better identify, visualize, and resect a specific structure/tissue during the intervention. Fluorescence can bring important assets when it comes to seeing better—the vessels, the lymph nodes, and the tumor itself. Some organs, such as the case of the ureter, are also much better underlined with the technique of NIR-ICG (near-infrared light and indocyanine green [ICG]), and therefore, the risk of producing a lesion secondary to incomplete visualization is smaller. This chapter closely looks at the literature on the theme of ICG in colorectal surgery, offering also a general frame made out of significant research, mainly systematic reviews and randomized controlled trials about the use of ICG in visceral surgery.
According to the definition given by the Merriam-Webster dictionary, a dye or a stain is able to penetrate living cells or tissues without inducing immediate obvious degenerative changes and thus, it is also called a vital stain. Supravital staining implies the removal of living cells from an organism, whereas intravital staining involves injecting (or otherwise administering) the dye into the organism. The term “vital stain” is sometimes used to refer to an intravital stain, and in some other situations, it is interchangeable with a supravital stain, the main idea being that the cell being looked at is still alive. In a more strict way of speaking, the term “vital staining” has a meaning which is opposite to “supravital staining.” If living cells take up the stain during supravital staining, living cells exclude the dye during “vital staining”; for example, they color negatively and only dead cells color positively, and hence, viability can be measured by counting in percentage the amount of total cells that stain negatively. Because the nature of the dye defines if the staining is either supravital or intravital, a mix of supravital and vital dyes can be employed to better categorize cells into various groups (e.g., viable, dead, dying) (Figures 1 and 2).
Metallic green sheen characteristic colonies of
A vial of methylene blue.
Tissue staining, also known as chromoscopy, can be used as an adjuvant technique in gastrointestinal endoscopy to help with the recognition of subtle lesions, such as is the case with polyps or, more so, allows to directly target biopsies, which may happen in the case of Barrett’s esophagus, in order to increase the precision of the diagnosis. Four endoscopic staining techniques have been described—vital staining (the use of an agent that is absorbed by the intestinal epithelium), contrast staining (the use of a substance to accentuate the aspect of the surface), reactive staining (the use of an agent that can fire chemical reactions), and tattooing (a technique using agents such as India ink to underline a special lesion on the mucosa).
Tissue stains used in gastrointestinal surgery, as mentioned by Fennerty [1], can be classified as follows:
tattooing agents
India ink is used for permanent marking of the mucosal site for relocalization at the time of surgery or endoscopy, also used in the esophagus, stomach, and colon, which is safe without side effects.
Indocyanine green is a shorter-duration tattooing agent with more information offered in the following section.
absorptive stains
Lugol’s iodine (stains normal glycogen containing squamous mucosa of the esophagus, allowing recognition of abnormal squamous epithelium—dysplasia—or metaplastic epithelium—Barrett s esophagus),
methylene blue and toluidine blue (stains the absorptive epithelium small bowel and colon), allowing the identification of metaplastic epithelium in the esophagus (Barrett s esophagus) and stomach (gastric intestinal metaplasia), can also find a negative stain in gastric metaplasia at the level of the duodenal bulb.
contrast stains
indigo carmine and cresyl violet (accentuates mucosal topography, allowing recognition of abnormal small bowel sprue and colonic mucosa inflammatory bowel disease, polyps).
reactive stains
Congo red (identifies acid-secreting portions of the stomach postoperatively and documents achlorhydria) and
phenol red (identifies alkaline areas of the stomach).
According to the definition offered by www.britannica.com, fluorescence is the emission of electromagnetic radiation, usually visible light, caused by the excitation of atoms in a material, which then reemit almost immediately (within about 10 s). The initial excitation is frequently determined by the absorption of energy from incident radiation of particles, as is the case with X-rays or electrons (Figure 3). Due to the fact that reemission happens so quickly, the fluorescence stops when the exciting source is removed, unlike the phenomenon of phosphorescence (Figure 4), which later persists as an afterglow.
High-resolution fluorescent microscope image of clusters of tumor cells in red surrounded by normal cells and normal skin in green. Photo source:
Research sample slide of tumor tissue where cells have been stained for different proteins using a fluorescently tagged antibody. Presented as false-color image on white background.
Fluorescence imaging techniques have become increasingly common in recent years. ICG-based fluorescence, in particular, is now widely used in a variety of diagnostic and treatment procedures, according to the research made by Nowaka and co [2]. ICG is currently the most commonly used fluorescent agent due to its gradual degradation and the rarity of the severe adverse effects described. ICG is a water-soluble, amphiphilic tricarbocyanine probe with a molecular weight of 776 Da, relatively nontoxic, unstable compound, a dye in clinic use bound by albumin in the intravascular space until rapid clearance by the liver. Severe allergic reactions associated with the use of ICG are very rare (1:10,000) with an incidence of 0.05% and mostly occur in patients allergic to iodine. It has various applications in different fields, such as cardiology, ophthalmology, and neurosurgery, but its fluorescent properties have only recently been applied to the intraoperative estimation of tissue blood supply. Apart from ICG, other substances can act as fluorophores (fluorescent chemical compounds that are able to reemit light upon light excitation), such as methylene blue, five-aminolevulinic acid, fluorescein sodium.
What is fluorescence-guided surgery (FSG)? FSG is employed because white visible light makes various tissues appear either identical or highly similar, and proper tumor identification can be difficult, according to www.isfgs.org [3]. Moreover, the surgeon just sees the tissues from the superficial layers under natural light. Nonetheless, structures that were previously invisible can be seen now and recognized by using ICG in a different light length. By combining visual abilities with special dyes, it is now possible to avoid such organs or structures during the surgical process in order to avoid harming them. Other benefits of the FSG include the ability to minimize operative time and the need for second-look procedures by facilitating the rapid detection of structures and lesions while avoiding excessive harm.
ICG has found application in several fields of general surgery, especially colorectal surgery (seen in the next section of the present article), esophageal surgery, and emergency evaluation of intestinal perfusion in cases of mesenteric ischemia, kidney transplantation, hepatobiliary, and endocrine surgery.
ICG can improve the harvesting of tumors during surgery and can properly adjust both the indications, as the extent of the intervention. In a systematic review performed in 2020 by Baiocchi [4], which took into account 192 screened papers with six series meeting the eligibility criteria, there were analyzed in total 353 peritoneal nodules, the neoplasms in question being—colorectal, hepatocellular, ovarian, endometrial. The above-mentioned study had as a purpose to look at the available clinical data regarding the value of ICG fluorescence imaging for intraoperative detection of peritoneal carcinomatosis during open surgery and the main aspects studied settled to the conclusion that sensitivity varied from 72.4 to 100%, while the specificity ranged from 54.2 to 100%.
The ICG fluorescence method is being used more and more in liver surgery due to the fact that it permits the real-time display of the segmental anatomy of the organ, depending on the tumor’s characteristics, and, more so, it is possible to perform direct or indirect identification of hepatic lesions and metastases. Additionally, ICG imaging allows more sensitive detection of tumor foci and, therefore, also a higher R0 resection rate. However, in a systematic review of the literature on the application of ICG imaging in open and laparoscopic liver surgery performed by Sucher et al. [5], the conclusion was drawn toward the aspect that the application resulted mainly useful for superficial lesions, as the depth of penetration of NIR is only 8–10 mm. In liver resections, post-hepatectomy liver failure (PHLF) can occur although an adequate liver volume is kept in place. Diverse dynamic functional tests, such as the indocyanine green test (ICG), could only appreciate globally the liver function, with no definition toward the functional ability of the hepatic remnant. Magnetic resonance imaging (MRI) with liver-specific contrast agents makes the evaluation of both liver function and volume possible. A preoperative combination between dynamic quantitative tests, such as ICG, with MRI or HBS (hepato-bilio-scintigraphy), should provide a more complete functional evaluation. One should opt for various functional tests to predict PHLF that should be selected according to patient’s characteristics, disease, and center experience, as shown by Tomassini and the team [6].
The incidence of skin flap necrosis after mastectomies can reach 11–24%. Laser-assisted ICG angiography appears as a promising technique to assess skin flap perfusion. In a systematic review performed by Driessen et al. [7], it was found that all studies looking at the current ICG methodology and ability to predict outcome showed a substantial decrease in skin necrosis when the ICG was used.
Endometriosis is a very commonly encountered disease that is found in up to 10% of the female population. The use of (ICG) has been advocated for the proper location of endometriotic lesions intraoperatively. NIR-ICG is useful in appreciating the blood supply of bowel anastomoses after segmental resection, according to a systematic review done by Ianieri et al. [8] that looked at 53 studies.
Iatrogenic ureteral injury in abdominal surgery is rare at the moment, although it can still result in significant morbidity and mortality. Inspection and palpation are two traditional methods of measuring iatrogenic ureteral damage, which can be difficult during laparoscopic procedures. The use of NIRF imaging to aid in better visualization of the ureters is currently being investigated. The report’s goal performed by Slooter et al. [9] was to picture the currently available and experimental dyes in ureter visualization and to further evaluate their feasibility of using them and, more so, to look at their effectiveness.
Several studies, among which the one performed by Copaescu [10], aimed to look at the reliability of a novel fluorescence-guided laparoscopic technique to correctly find the site of unknown gastrointestinal bleeding, with the help of the vascular washout properties of indocyanine green (ICG). The bleeding site was correctly identified and the patient benefited from a minimally invasive technique, and it was, therefore, possible to avoid an open surgical exploration.
This represents another important topic in different surgical fields, for instance, urology, gynecology, and general surgery.
In the early stage of breast cancer, ICG-fluorescence-based sentinel lymph node (SLN) detection is being considered. A systematic review looking at 2301 patients from 19 studies found that ICG-fluorescence could complement the radioisotope method or provide an alternative. Another study regarding the ICG lymph node technique in breast cancer was a literature review presented by Benson [11] in which a significantly better sentinel node detection rate was found with ICG than with the standard radioisotope method (Figure 5).
The surgeon uses a portable fluorescence imaging device during breast removal. Photo source:
Techniques that combine the ability to identify technetium-99 and a blue dye have been widely used for sentinel lymph node biopsy (SLNB), but there has recently been a surge of interest in the use of fluorescent staining, such as indocyanine green (ICG), to improve the rate of SLN detection. Even though recent guidelines recommend sentinel lymph node biopsy in addition to PLND, SLN biopsy alone is not yet the gold standard because there is insufficient prospective evidence, especially in terms of long-term oncological protection. The prospective randomized clinical trial SENTICOL III will answer to these signaled issues, as a study by Balaya et al. [12] mentions. In addition to the facts mentioned above, the prospectively randomized FILM trial evaluated ICG to be superior in lymph node detection compared to isosulfan blue dye in patients with stage I endometrial or cervical cancer, an evaluation performed by Frumovitz and team [13]. Meanwhile, the study’s conclusions created a context for the FDA’s approval of ICG for lymph node mapping. NCCN guidelines mention sentinel lymph node mapping by ICG in cervical cancer patients, according to Koh et al. [14].
Anastomotic leakage remains among the most feared and challenging complications after colorectal resection. The etiology of leaks includes patient factors, technical factors, and anastomotic perfusion. The known etiology of leaks includes the following: different patient factors, technical factors, and anastomotic blood supply. An intact anastomotic irrigation pattern is particularly vital in the process of anastomotic healing. The air leak testing and intraoperative colonoscopy are methods that can be done to establish the anastomotic integrity intraoperatively. Among the major causes of anastomotic leakage is impaired vascularization and a minimal deficit in blood supply, both aspects being difficult to detect under white light. Fluorescence angiography with indocyanine green (ICG-FA) is employed in colorectal surgery in order to evaluate the blood supply in the area of an anastomosis. Studies with ICG-FA in open and laparoscopic interventions indicated a lower rate of anastomotic leakage; for example, the PILLAR II study reported a leakage rate of 1.4%. There were researches in this field, such as is the case of Carus and Pick [15] that reported impressive results in clinical outcome and patient prognosis. Likewise, the use of ICG-FA in the group of patients studied potentially led to a reduction of the leakage rate by 48%. Another systematic review from Blanco-Colino and Espin-Basany [16] looks at 1302 patients from five nonrandomized studies in which fluorescence imaging significantly decreased the anastomotic leak in cases operated on for colorectal cancer. Lower leak rates were found in rectal cancer surgery, as well (ICG 1.1% vs. non-ICG 6.1%; p = 0.02) (Figure 6).
X-ray angiography of the inferior mesenteric artery (IMA) with contrast media. Its supplies arterial blood to organs of hindgut-distal 1/3 of the transverse, splenic flexure, descending colon, sigmoid, rectum.
Indocyanine green fluorescence imaging can also be used as a potential tool for enhancing the accuracy of the staging of patients with primary colorectal cancer through the detection of sentinel lymph nodes. The search in electronic databases was performed and eligible data were taken from 248 patients in a review published by Emile et al. [17], which looked at the overall sensitivity and specificity of (ICG) (NIR) fluorescence in sentinel lymph node detection in colorectal cancer. The median values for the sensitivity, specificity, and accuracy rates were 73.7, 100, and 75.7, respectively. Other several studies, even though none was a prospective one, considered the ICG method feasible in colorectal cancer and also for lower rectal tumors, especially in order to detect the lymphatic drainage across the lateral lymph nodes, as studied by the teams of Nagata et al. [18], Kawahara et al. [19], Cahill et al. [20], and Liberale et al. [21]. Another method used in correctly and precisely identifying the lymph node involvement is one-step nucleic acid (OSNA), as it can offer a quick method of characterization of the lymph nodes. On the other hand, near-infrared (NIR) laparoscopy, together with indocyanine green (ICG), can identify relevant nodal tissue
A study performed by Vuijk et al. [23] looking at the lymph node involvement in gastrointestinal tumors assessed the sentinel lymph node technique with Nanocoll, and ICG- and CEA-targeted fluorescent imaging, and settled to the following conclusions: sentinel lymph node interventions in gastric cancer resections using indocyanine green (ICG) linked to Nanocoll outperformed normal ICG, but could not offer details on possible lymph node metastasis. Besides that aspect, the carcinoembryonic antigen (CEA)-targeted fluorescent imaging technique by using SGM-101 was successful in both pancreatic and colorectal cancers. A large phase III multicenter trial with the corresponding results would be able to complete the missing data.
Simultaneously, in which concerns lymph node invasion, the concept of ultrastaging appeared recently in the specific literature. Furthermore, studies were compiled, such as the one by Hirche et al. [24], in which regards ultrastaging of colon cancer by sentinel node biopsy using fluorescence navigation with ICG Overall, the ICG fluorescence technique found a mean of 1.7 sentinel lymph node (SLN) in 25 out of 26 patients (with a detection rate of 96%). Metastatic involvement of the SLN was detected in 9 out of 11 nodal positive patients by conventional histopathology. The sensitivity of the method was 82% in the case of colon carcinoma. The drawn conclusion of the abovementioned study was that the ICG fluorescence technique is a new but feasible method for SLNB of colon carcinoma and permits ultrastaging with improved accuracy, but with limited validity (so far) due to the small number of cases (Figures 7 and 8).
Colorectal cancer concept. Development of cancer from the colon or rectum to the whole large intestine. Stages of spreading tumor to the lymph nodes and vector flat illustration of other internal organs.
Metastatic colon carcinoma, in lymph node. Tumor component is on the left and lymphoid component is on the right, magnification 200×.
ICG is metabolized by the liver and accumulates in areas of slower bile metabolism, a situation that can be encountered in primary liver cancers and colorectal secondary determinations (metastases), as found by the teams of Peloso et al. [25] and van der Vorst [26]. A tumor cluster of cells as small as 200 tumor cells can be identified by ICG, allowing surgeons to find foci of a minimum of 1 mm, as it was shown by Ishizawa et al. [27]. The practical aspect of finding liver masses is that they have to be superficial, and the fluorescence methods can look at the maximum depth of infiltration of up to 10 mm. A combination of the application of intraoperative ultrasound and fluorescence techniques was shown to increase the identification rate of colorectal metastatic lesions, as it was researched by Kaibori et al. [28]. In patients suffering from liver fibrosis, nevertheless, areas that have a slow bile metabolism might give false-positive fluorescence. ICG fluorescence can be employed to qualitatively and quantitatively depict changes at a molecular and cellular level in the living organism, and to objectively display liver tumor information, to define hepatic tumor boundaries, and to detect residual tumors, achieving an intraoperative real time coloration and the successful navigation of the liver parenchyma in the targeted zone, as mentioned by Shizawa et al. [29]. A recent meta-analysis included studies on 587 patients showing that ICG fluorescence in the field of liver surgery does decrease operative time, blood loss, hospital stay, and postoperative complications if we are to mention a study done by Qi et al. [30]. As mentioned in subchapter 3.2.2 (ICG in liver surgery), the ICG fluorescence technique is for sure viewed as an intraoperative method that allows the detection of additional superficial hepatic metastases of colorectal cancer, a fact underlined by Liberale and team [31] in an article in which PubMed and Medline literature databases were searched for articles on the use of ICG in the setting of clinical studies on CRC (Figures 9 and 10).
Immunofluorescence of multiple human tumor metastatic cells growing in tissue culture for research purposes.
Human liver cancer cell growth. 3D illustration.
As previously shown in the previous subsections of the chapter, ICG fluorescence imaging is increasingly being used, tested, and documented in different areas of abdominal surgery. The constant improvement in the method and in the technological possibilities enables easy use and facilitates operative decision-making, also in robotically assisted colorectal surgery, as it is communicated in a study published by Vilz et al. [32]. Additional information offered there was that the first individual studies underlined an important reduction in the incidence of anastomotic leakage after colorectal anastomosis through the use of ICG fluorescence angiography (FA, 9.1% vs. 16.3%; p = 0.04). First feasibility research studies also emphasized lymph node detection or navigation, as well as the possibility to visualize the ureter (Figure 11).
Robotic surgery in the operation room.
In regard to tumor localization, ICG-coated endoscopic clips can bring a promising new technique, as seen in a study by Lee et al. [33]. The precise localization of a tumor before surgery is vital, more so in the early stages of cancer, and the amplitude of the surgical intervention must be established. The accurate localization of a colorectal lesion ensures proper margins for resection and prevents surgical removal of healthy segments of the colon; furthermore, it can reduce the duration of surgery and prevent unnecessary colon traction and tumor handling, which could result in dissemination of tumor cells. The method abovementioned involves placing endoscopic clips coated or mounted with near-infrared fluorescent material, such as ICG, at the lesion site and determining the location of the tumor by consequently detecting the fluorescent signal through the intestinal wall (through the use of a near-infrared laparoscope).
In a research by de Nardi and team [34], a randomized trial was formulated, involving 252 cases in which laparoscopic left-sided colon and rectal resection were performed. The algorithm randomized 1:1 to intraoperative ICG or to subjective visual evaluation of the bowel blood supply without ICG. The main results were the following: ICG angiography documented insufficient blood supply of the colic stump, which implied extended bowel resection in 13 cases (11%). In the control group, 11 patients (9%) had a fistula; meanwhile, in the study group, six patients (5%) developed one anastomotic leak (p = n.s.).
Based on the general elements reviewed, it was summed up that intraoperative ICG fluorescence angiography can efficiently find correctly the vasculature of the colic stump and anastomosis in situations when colorectal resection is performed.
Despite the fact that this method guided proximal bowel resection in 13 instances, the ICG arm did not find a statistically meaningful decrease in anastomotic bowel leak rate. Transanal ICG angiography has been shown to be both feasible and effective in imaging the mucosal and anastomotic blood supply in research conducted by Sherwinter [35]. Future research in a larger community of patients is needed to fully understand the technique’s potential to detect flaws in tissue perfusion that could lead to an anastomotic breakdown. Twenty patients with benign and malignant lesions underwent low anterior resection for the analysis. Indocyanine green (ICG) was injected through a peripheral iv catheter after the anastomosis was completed. Transanally, an endoscopic near-infrared imaging device (NIR) was used to test the blood supply at the level of the colon mucosa, the rectum, and the anastomotic staple axis (Figure 12).
Schematics of fluorescence angiography in the colorectal area.
The incidence of the incisional surgical site infections in colorectal surgery was reported between 5 and 26%. Surgical site infections (SSI) in an abdominoperineal resection (APR) appear more than in other types of interventions in the case of patients with colorectal cancer. Toshiyuki et al. [36] found that perineal wounds are the most vulnerable sites, and they may be triggered by stool contamination. Indocyanine green (ICG) fluorescence testing was employed as a marker of perineal wound contamination. The study had as a method to inject indocyanine green into the rectum transanally before the operation, and fluorescence images were obtained during the operation in patients who underwent APR. The findings, though sparse, are promising: one subject had an SSI after having no clear gross contamination, and a trace of ICG fluorescence was found in the perianal skin.
The other two cases were free of SSI, and skin treatment was carried out thoroughly before ICG contamination was removed in those cases.
Even after the normal antiseptic skin preparation, a trace of stool contamination can remain in the perineal skin area, according to the study’s findings.
Furthermore, careful skin preparation is needed and it is compulsory if we are to minimize stool contamination in APR subjects (Figure 13).
A perineal wound with infection and inflammation after colorectal surgery.
India ink has been largely used for preoperative colonic tattooing, but different complications have been reported. A study performed by Miyoshi et al. [37] looked at the surgical usefulness of ICG as an alternative to India ink for endoscopic marking and evaluated 40 patients between the time of ICG marking and the intervention, the median time period was 4 days (range, 1–73 days).
At the time of surgery, all 29 patients who were operated on within 8 days of tattooing stained positive in green with ICG dye.
Positive staining was clearly obviated in just two of the remaining 10 cases after 9 days or more.
The staining faded over time and finally vanished.
There was no mention of the dye’s perioperative side effects.
The authors concluded that this study supports the use of ICG as a safe approach that may be consistently detected within 8 days of endoscopic injection (Figure 14).
Colon polyp removal. Endoscope inside colonoscopy for colon polyps.
Efficacy of oral or rectal administration of indocyanine green solution. In a study realized by Sou et al. [38] whose objectives were to detect enterovesical occult microfistulas in patients with Crohn’s disease before the fistulas had become readily apparent, nonhazardous enteral administration of indocyanine green solution was performed. The methods that were used collected a total of 12 patients with Crohn’s disease who were suspected from their clinical manifestations of having enterovesical fistulas. Urine was collected and tested for contamination with indocyanine green by using a colorimeter to detect fistulas following oral or rectal administration of the indocyanine green solution. In addition, the efficacy of the indocyanine green test was compared to that of the “classical” X-ray sample.
The ICG test was positive in 11 of the 12 cases after either oral or rectal administration, resulting in a 92% correct diagnosis rate (11/12 patients).
The percentage of right diagnoses using an X-ray analysis, on the other hand, was just 17% (2/12 patients).
Furthermore, none of the eight patients with secret fistulas could be accurately diagnosed using an X-ray analysis, but all showed promising results when the indocyanine green approach was used.
The researchers concluded that the indocyanine green test had a 92% accuracy rate in diagnosing obscure fistulas and was highly diagnostic, while traditional examinations are often complicated and inaccurate (Figure 15).
Intraoperative macroscopic enterovesical fistula.
Peritoneal metastases can appear in 30–40% of patients with colorectal cancer and in a quarter of the patients might be the cause of death. ICG-guided surgery was able to detect additional lesions, and some studies reported up to 21.4% with a direct impact on modifying the surgical resection technique (Figure 16).
Extensive lesions of peritoneal carcinomatosis.
Fluorescence-assisted surgery using near-infrared (NIR) light is a relatively new technique.
To improve the visible spectrum, this technique uses a combination of dyes and NIR imaging equipment.
As a result, it may provide more detailed anatomic and functional details, allowing for a more complete resection of a neoplasm or the protection of essential normal structures. Indocyanine green fluorescence technique is a surgical tool with increasing perioperative and intraoperative applications in colorectal surgical interventions. In colorectal surgery, in particular, several studies have shown that intraoperative fluorescence imaging is a safe and feasible method to evaluate anastomotic perfusion, and its use might positively affect the patient’s clinical outcome by decreasing the incidence of anastomotic leaks. The number of virtual uses for indocyanine green is enhancing and developing, including new ways to detect and control colorectal metastases to the liver. All these advances expanded by the further evolution in time with more prospective trials could offer great information and value for both surgeons and patients, by improving the accuracy and outcomes of general surgery and surgical oncology.
The author declares no conflict of interest.
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