Study of Learning Curve in a Surgeon for Near-Infrared Fluorescence Cholangiography During Laparoscopic Cholecystectomy-A Retrospective Evaluation

Abstract

Background Near-infrared indocyanine green fluorescence cholangiography (NIRF) has shown promising results on delineating extra-hepatic biliary anatomy during laparoscopic cholecystectomy to avoid bile duct injury. However its routine usage remains in question. In this study, the technique was evaluated further with learning curve estimation and learning factors were observed. Methods One hundred ninety-nine cases which underwent laparoscopic cholecystectomy for acute or chronic cholecystitis within a 2-year period including 51 cases with initial use of NIRF by 2 surgeons were studied retrospectively. The learning curve was evaluated for a surgeon as primary objective. A case-matched comparison of the operative time between NIRF and conventional group, in terms of acute and chronic cholecystitis was also conducted as a secondary calculation. Results Learning curve was evaluated with 61% learning rate for NIRF experience. Cysto-biliary junction non-illuminated cases under fluorescent view, had mean operative time of 80.83 ± 22.82 min, which was shorter than the cysto-biliary junction illuminated cases. The NIRF group exhibited longer operative time compared with the conventional group with mean difference of 34.39 min (significant at P < .05). Conclusions While the initial learning phase might be affected by surgeons’ behavior and attitude, our results may provide a reference to learn at one’s own pace and to employ NIRF teaching strategies during surgical training programs to overcome the initial phase during training period itself and facilitate universal achievement.

Biliary Anatomy Visualization and Surgeon Satisfaction Using Standard Cholangiography versus Indocyanine Green Fluorescent Cholangiography during Elective Laparoscopic Cholecystectomy: A Randomized Controlled Trial

“…It is a non-invasive modality, which does not require manipulation of the cystic duct, thus limiting the rate of iatrogenic BDI. The ability for an easy and fast switch between the standard white-light mode and NIR fluorescence enables sufficient real-time biliary mapping, while near-infrared fluorescence cholangiography does not require a patent cystic duct and constitutes a valuable tool for the education of novice surgeons, increasing intraoperative safety [40]. In the case-control study by Quaresima et al, the authors concluded that ICG-FC led to an increased number of cholecystectomies, even in challenging cases of acute cholecystitis and empyema, performed by resident doctors due to increased intraoperative confidence in delineating anatomical landmarks [41].…”

Hepatobiliary surgery in Taiwan: The past, present, and future. Part I; biliary surgery

“…Precision in surgery should refer to follow a precise anatomical roadmap such as navigation and augmented reality offering anatomic biliary tree to avoid ductal injury. [94] Similar to precision oncology, precision surgery relies on the use of advanced technology, for example, artificial intelligence used for predicting the risk of surgery, detecting occult tumor metastatic lesion, and avoiding nerves injury www.e-fjs.org during operation. [111] The development of precision surgery will benefit our patients, and the surgeons of today must learn to practice precision surgery for our patients.…”

“…Near-infrared fluorescence cholangiography provides a clear visualization of the common bile duct in cases of cholecystitis with mild adhesions and of the anatomy of the biliary tree in cases of severe inflammation; however, it provides no benefits in cases of noninflamed cholelithiasis. In 2020, Tseng et al [94] from Show Chwan Memorial Hospital initially applied NIRFC on 51 LC patients for acute or chronic cholecystitis and indicated that NIRFC group had better learning curve but longer operative time compared with the conventional LC group. In our future, we can pay attention to the European registry on fluorescence-guided surgery confirmed a wide disparity in terms of protocols for NIRFC particularly in terms of indocyanine green dose and timing of administration for our trainee in the future.…”