Near-infrared fluorescent cholangiography facilitates identification of biliary anatomy during laparoscopic cholecystectomy

Abstract

BACKGROUND Intraoperative cholangiography (IOC) is the current gold standard for biliary imaging during laparoscopic cholecystectomy (LC). However, utilization of IOC remains low. Near Infrared Fluorescence Cholangiography (NIRF-C) is a novel, noninvasive method for real-time, intraoperative biliary mapping. Our aims were to assess the safety and efficacy of NIRF-C for identification of biliary anatomy during LC. METHODS Patients were administered indocyanine green (ICG) prior to surgery. NIRF-C was used to identify extrahepatic biliary structures before, and after partial and complete dissection of Calot's triangle. Routine IOC was performed in each case. Identification of biliary structures using NIRF-C and IOC, and time required to complete each procedure were collected. RESULTS Eighty-two patients underwent elective LC with NIRF-C and IOC. Mean age and BMI were 42.6±13.7 years and 31.5±8.2 kg/m2, respectively. ICG was administered 73.8±26.4 minutes prior to incision. NIRF-C was significantly faster than IOC (1.9±1.7 vs. 11.8±5.3 minutes, p<0.001). IOC was unobtainable in 20 (24.4%) patients while NIRF-C did not visualize biliary structures in 4 (4.9%) patients. After complete dissection, the rates of visualization of the cystic duct, common bile duct, and common hepatic duct using NIRF-C were 95.1%, 76.8%, and 69.5%, respectively, compared to 72.0%, 75.6%, and 74.3% for IOC. In 20 patients where IOC could not be obtained, NIRF-C successfully identified biliary structures in 80% of the cases. Higher BMI was not a deterrent to visualization of anatomy with NIRF-C. No adverse events were observed with NIRF-C. CONCLUSIONS NIRF-C is a safe and effective alternative to IOC for imaging extrahepatic biliary structures during LC. This technique should be evaluated further under a variety of acute and chronic gallbladder inflammatory conditions to determine its usefulness in biliary ductal identification.

Clinical value and pitfalls of fluorescent cholangiography during single-incision laparoscopic cholecystectomy

“…The mean interval between the ICG injection and the first obtained fluorescent cholangiography in our study (39 ± 4 min) was similar to what has been reported previously (range 33-74 min) [4][5][6]. In our study, the interval between the ICG injection and the first obtained fluorescent cholangiography was not associated with detectability of the biliary structures; however, the fact that the gallbladder could be identified under fluorescent cholangiography before dissection in Calot's triangle in all our patients indicated that the interval between the ICG injection and the first obtained fluorescent cholangiography was sufficient for us to start assessing the detectability of the biliary structures during SILC.…”

“…The clinical value of fluorescent cholangiography during conventional laparoscopic cholecystectomy is becoming clearer [1][2][3][4][5]. High detectability of biliary structures during conventional laparoscopic cholecystectomy has established the usefulness of fluorescent cholangiography.…”

“…Although several authors have reported on the clinical value of fluorescent cholangiography using indocyanine green (ICG) during conventional laparoscopic cholecystectomy [1][2][3][4][5], its utility during single-incision laparoscopic cholecystectomy (SILC) remains unclear. Complicated cholecystectomy has conventionally been excluded from indication criteria of SILC; therefore, the clinical value of fluorescent cholangiography during SILC was only able to be evaluated in selected patients [6].…”

The emerging role for robotics in cholecystectomy: the dawn of a new era?

“…Though the role of routine ICGC on common bile duct injury on a larger scale has yet to be evaluated, surgeons using this technology have demonstrated that it is safe with no ductal injuries reported in their clinical practices (38). Several studies have demonstrated equal or improved visualization of biliary anatomy and anatomic variants with ICGC, without the added time and morbidity associated with traditional intra-operative cholangiography (39,40). In addition, the conversion to open procedures has been decreased with the utilization of this technology (41).…”

Minimalist approach to donor hepatectomy

“…If it is rather short, or if it is absent entirely, ductal division without cholangiography guidance can be hazardous to the donor and may render recipient ductal reconstruction difficult and suboptimal. Near-infrared fluorescence cholangiography may be helpful for more precise determination of the line of division of the right hepatic duct [3]. As indocyanine green is excreted into the main ducts, fluorescence makes the ducts more visible, so the surgeon has a better picture of the biliary anatomy.…”