Intraoperative exploration of biliary anatomy using fluorescence imaging of indocyanine green in experimental and clinical cholecystectomies

Abstract

Background/purpose We evaluated the usefulness of intraoperative exploration of the biliary anatomy using fluorescence imaging with indocyanine green (ICG) in experimental and clinical cholecystectomies. Methods The experimental study was done using two 40-kg pigs and the clinical study was done in 12 patients for whom cholecystectomy was planned from January 2009 to June 2009. Initially we used a laparoscopic approach for the evaluation of fluorescence imaging of the biliary system in the two pigs. Then the clinical study was started on the basis of these experimental results. ICG (1.0 ml/body of 2.5 mg/ml ICG) was infused 1-2 h before surgery. With the subjects under general anesthesia we observed in real time the condition of the biliary tract under the guidance of fluorescence imaging employing an infrared camera or a prototype laparoscope. ICG was added intravenously to observe the location or flow condition of the cystic artery. Results We obtained a clear view of the biliary tract and the location of the cystic duct in the two pigs. Local compression with a transparent hemispherical plastic device was effective for offering a clearer view. The biliary tract, except for the gallbladder, was clearly recognized in all clinical subjects. Local compression with a transparent hemispherical plastic device for open cholecystectomy and a flat plastic device for laparoscopy provided clearer visualization of the confluence between the cystic duct and common bile duct or common hepatic duct. The location of the cystic artery was revealed after division of the connective tissues, and the flow condition of the cystic artery was confirmed 7-10 s after intravenous re-infusion of ICG. There were no adverse events related to the intraoperative procedure or the ICG itself. Conclusions This method is safe and easy for the identification of the biliary anatomy, without requiring cannulation into the cystic duct, X-ray equipment, or the use of radioactive materials. Although fluorescence imaging is still at an early stage of application in comparison with ordinary intraoperative cholangiography, we expect that this method will become routine, offering a lower degree of invasiveness that will help avoid bile duct injury.

Near-Infrared Fluorescence Imaging in Patients Undergoing Pancreaticoduodenectomy

“…This is in concordance with preclinical data described by Matsui et al [30] and clinical studies of patients undergoing cholecystectomy [29,31]. A useful contrast between the common bile duct and surrounding tissue was observed ≥10 min after injection.…”

“…Because ICG is almost exclusively excreted into the bile, it can also be used for intraoperative NIR fluorescence exploration of the biliary anatomy [29,30,31]. This can be useful in patients with a difficult laparoscopic cholecystectomy, due to an aberrant biliary anatomy or an acute cholecystitis, for example.…”

Comparing Near-Infrared Imaging with Indocyanine Green to Conventional Imaging During Laparoscopic Cholecystectomy: A Prospective Crossover Study

“…[30][31][32][33][34][35][36]38 For example, Schols et al 30 performed a feasibility study in a series of 15 laparoscopic cholecystectomies in which use of NIR-ICG facilitated significantly earlier identification and a clear delineation of both CBD and CD-in agreement with the results of our study. Using ICG, Ishizawa et al 32 reported identification of CD and CBD in a series of 52 patients undergoing laparoscopic cholecystectomy.…”

“…[27][28][29][30][31][32] The various moments at which ICG injection has been reported include 30-60 minutes before arrival in the operating room or the start of surgery, to just before induction of general anesthesia, and even following endotracheal intubation. [31][32][33][34][35][36] The dose used in the present study was 0.05 mg/kg. The first and third patients received ICG 1-2 hours prior to the start of surgery, based on the reported peak in concentration of ICG in bile 120 minutes after intravenous injection.…”

Near-infrared fluorescence cholangiography assisted laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy (FALCON trial): study protocol for a multicentre randomised controlled trial

“…By real-time identification of the vital structures being the CD and CBD within the already adapted CVS technique, it may improve the outcome of LC. 16 27 28 NIRF imaging using ICG has been evaluated in various animal models [29][30][31] and in open, laparoscopic and single-incision laparoscopic cholecystectomies. 30 32-34 Promising results were presented for safe and successful intraoperative identification of the CBD and the CD, compared to conventional laparoscopic imaging.…”