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Fishbone bowel perforation mimicking acute diverticulitis: a diagnostic dilemma

tal urological anomalies with an incidence of 0.7–4% of the population and occurs more commonly in females. Whilst the majority of individuals with duplicated ureters are asymptomatic, it may be associated with vesicoureteric reflux, obstructive uropathy, renal parenchymal scarring or reduced renal function. Complete ureteral duplication occurs when two separate ureteric buds arise from the mesonephric duct and migrate to meet the metanephros. This results in two ureters draining each pole of the kidney. The presence of duplex ureters may increase the risk of iatrogenic injury. Sound anatomical knowledge of the course of the ureter in the pelvis remains important in preventing iatrogenic injuries. However, with the increasing uptake of minimally invasive surgery, traditional methods to assist identification of ureters intraoperatively, such as insertion of ureteric stents, are limited due to lack of haptic feedback. ICG is an anionic, water-soluble but relatively hydrophobic molecule that binds to plasma proteins when injected intravenously and is exclusively excreted by the liver. When injected into the ureter, ICG reversibly binds to proteins on the urothelial lining. ICG becomes fluorescent when excited by light in the nearinfrared light spectrum (approximately 820 nm) emitted by a xenon light source. The infrared emission is then captured on a filtered lens system and is projected onto a monitor in fluorescent green. This allows clear illumination of the ureter intraoperatively. It is important to note that the intensity of fluorescent green changes depending on its depth from the overlying tissue and hence careful dissection is still required. In this case, ICG gave us good visualization of the ureters intraoperatively and also allowed assessment of vascularity of the colonic anastomosis when administered intravenously. ICG also has many other uses including angiography of retinal vessels, visualizing biliary anatomy and measuring hepatic reserve in a cirrhotic liver. The cost of ICG is AUD147 per vial and when a compatible laparoscopic or robotic system is available, it can serve as a useful adjunct in preventing iatrogenic ureteric injuries particularly in complex abdominal and pelvic surgery.