Intraoperative Hyperspectral Imaging for Perfusion Assessment and Emerging Decision Support in Abdominal Surgery: A Systematic Review of Clinical Studies.

Background and Objectives: Intraoperative assessment of tissue perfusion remains a decisive but imperfect step in abdominal surgery. Surgeons still rely heavily on visual judgement when choosing bowel transection lines, constructing anastomoses, judging intestinal viability, or assessing graft reperfusion, even though these decisions are directly linked to anastomotic leak, conduit ischemia, postoperative liver dysfunction, and graft failure. Hyperspectral imaging (HSI) is an emerging contrast-free optical technology that generates quantitative maps of tissue oxygenation, hemoglobin distribution, water content, and near-infrared perfusion. The present review was designed to evaluate whether clinical intraoperative HSI has matured sufficiently to support a focused systematic review topic in abdominal surgery and to synthesize the currently available human evidence. Methods: A literature search was conducted up to 20 February 2026 using combinations of the terms "hyperspectral imaging", "HSI", "abdominal surgery", "colorectal", "hepatectomy", "transplantation", "pancreatoduodenectomy", "esophagectomy", "mesenteric ischemia", and "intraoperative". Eligible records were original human clinical studies evaluating intraoperative HSI in abdominal or transplant-related operations with perfusion, oxygenation, or tissue viability as a central endpoint. Review articles, animal studies, non-surgical diagnostic studies, and single-patient case reports were excluded. Data were synthesized narratively because of major heterogeneity in indications, designs, devices, timing of measurements, and reported outcomes. Results: Thirteen studies published between 2019 and 2024 met the eligibility criteria, representing 391 patients. The literature covered colorectal resection, acute mesenteric ischemia, esophageal reconstruction with gastric or colonic conduits, pancreatoduodenectomy, pancreas transplantation, major hepatectomy, liver transplantation, and minimally invasive system validation. Across colorectal studies, HSI frequently demonstrated discordance between visually selected and objectively perfused transection lines, with clinically relevant strategy changes in a substantial proportion of patients. In ischemic and transplant settings, HSI discriminated poorly perfused tissue, identified low near-infrared perfusion values associated with early allograft dysfunction, and quantified reperfusion patterns after clamping or implantation. The evidence base was dominated by prospective single-center feasibility studies with small to moderate sample sizes, and no randomized trials were identified. Conclusions: Clinical intraoperative HSI in abdominal surgery is a genuinely niche yet rapidly expanding topic with a sufficient number of human studies to support a relevant systematic review. Current evidence consistently supports feasibility, quantitative perfusion discrimination, and plausible intraoperative utility, especially in colorectal and transplant-related surgery. However, the field remains methodologically heterogeneous, and the next research priority is multicenter standardization with clinically anchored thresholds and outcome-driven comparative studies.