Name: 吲哚菁绿荧光在复杂腹腔镜胆囊切除术导航中的作用 (视频) | JoVE Journal
Uploaded: 2025-01-31T13:50:00.000+00:00
Duration: 3 min 27 s
Description: 了解吲哚菁绿荧光导航在复杂腹腔镜胆囊切除术中的应用方法。本研究通过术前静脉注射染料，优化胆管显影时机与剂量，提升术中导航精度并降低手术并发症风险。

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5 minutes

本工作得到国家自然科学基金（资助号 82272105）、广东省基础与应用基础研究基金（资助号 2022A1515011244、2023A1515011521、2023A1515010475）、广东省医学科研基金（A2017421、2016116212141586）的支持。

本研究遵循中山大学第五附属医院人体研究伦理委员会的指导方针进行。已从患者处获得书面知情同意，同意其参与本研究。复杂腹腔镜胆囊切除术（LC）的标准包括：胆囊壁水肿且增厚≥4 mm；坏疽性胆囊炎伴或不伴穿孔；上腹部手术史；胆囊颈部嵌顿结石；Mirizzi综合征或肝外胆管变异；以及需要经胆囊行胆总管探查的病例。材料表中提供了所用试剂和设备的详细信息。
1. 荧光成像准备与患者体位摆放
<ol>
	<li>注射 0.25 mg 的 ICG 通过 术前45分钟经外周静脉注射。 
	注意：将1瓶吲哚菁绿（ICG，25 mg）溶于10 mL生理盐水中。取1 mL该溶液加入100 mL生理盐水中稀释。给予10 mL稀释后的溶液 通过 手术前45分钟进行静脉注射。</li>
	<li>设置DPM-I荧光系统，该系统为双通道图像引导装置，可在白光（380–665 nm）和近红外（810–1200 nm）光谱范围内运行。</li>
	<li>将患者置于仰卧位。在实施全身麻醉（遵循机构批准的方案）并完成所有安全程序（头罩、无菌手套和无菌刷洗）后，建立无菌区域。采用四通道法进行套管插入。15.</li>
</ol>
2. 胆道结构的荧光引导可视化与识别
<ol>
	<li>切换至荧光模式以定位胆管。 
	注意：在荧光模式下，染色的胆管结构可能直接可见，或在简单分离包埋的脂肪组织后显现（图1A）。</li>
	<li>根据荧光导航，使用电凝钩仔细解剖并分离胆囊管（CD）和胆囊动脉（CA），以获得安全的关键视野，即所谓的Calot三角。 
	注意：在荧光模式下，胆囊管呈现荧光信号，而胆囊动脉则无荧光信号。</li>
	<li>在识别并区分胆管后，对胆囊管（CD）和胆囊动脉（CA）均应用Hem-O-lock夹。在胆囊管上近端放置两个夹子，远端放置一个夹子；在胆囊动脉上近端和远端各放置一个夹子。 
	注意：应仔细识别胆囊管与胆总管（CBD）的连接处，以防止意外损伤胆总管。</li>
</ol>
3. 胆囊切除
<ol>
	<li>从胆囊窝中解剖出胆囊，使用剪刀在夹闭处之间切断胆囊管（CD）和胆囊动脉（CA），并将胆囊放入取出袋中。</li>
	<li>采用白光模式检查是否有出血，并切换至荧光模式，以确认胆囊切除术后无胆汁渗漏。</li>
	<li>将胆囊从腹腔中取出，在胆囊窝处放置引流管，并使用4-0聚乙醇酸缝线关闭腹腔。用3-0不可吸收缝线缝合皮肤。 
	注意：尤其在存在胆道解剖变异（如右副肝管）的情况下，必须先确认仅有一条胆管进入胆囊后，方可切断胆囊管（CD）。</li>
</ol>
4. 术后监测与管理
<ol>
	<li>术后复查炎症指标。</li>
	<li>当腹腔引流液清亮且每日引流量少于 50 mL 时，拔除腹腔引流管。</li>
	<li>根据患者的临床状况及外科医生建议，必要时给予预防性抗生素。</li>
	<li>监测患者是否出现感染征象，包括发热、手术部位发红或肿胀。</li>
	<li>安排术后 7–10 天内随访，评估恢复情况。</li>
</ol>

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<li>Liu, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Investigation+of+the+optimal+indocyanine+green+dose+in+real-time+fluorescent+cholangiography+during+laparoscopic+cholecystectomy+with+an+ultra-high-definition+4K+fluorescent+system%3A+A+randomized+controlled+trial%5BTitle%5D)+AND+%22Updates+Surg%22%5BJournal%5D)">Investigation of the optimal indocyanine green dose in real-time fluorescent cholangiography during laparoscopic cholecystectomy with an ultra-high-definition 4K fluorescent system: A randomized controlled trial.</a> Updates Surg. 75 (7), 1903-1910 (2023).</li>
<li>Huang, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Real-time+fluorescent+cholangiography+with+indocyanine+green+in+laparoscopic+cholecystectomy%3A+a+randomized+controlled+trial+to+establish+the+optimal+indocyanine+green+dose+within+30+min+preoperatively%5BTitle%5D)+AND+%22Surg+Today%22%5BJournal%5D)">Real-time fluorescent cholangiography with indocyanine green in laparoscopic cholecystectomy: a randomized controlled trial to establish the optimal indocyanine green dose within 30 min preoperatively.</a> Surg Today. 53 (2), 223-231 (2023).</li>
<li>Lopez-Sanchez, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Dose+and+administration+time+of+indocyanine+green+in+near-infrared+fluorescence+cholangiography+during+laparoscopic+cholecystectomy+%28DOTIG%29%3A+Study+protocol+for+a+randomised+clinical+trial%5BTitle%5D)+AND+%22BMJ+Open%22%5BJournal%5D)">Dose and administration time of indocyanine green in near-infrared fluorescence cholangiography during laparoscopic cholecystectomy (DOTIG): Study protocol for a randomised clinical trial.</a> BMJ Open. 13 (3), e067794(2023).</li>
<li>Esposito, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Clinical+application+and+technical+standardization+of+indocyanine+green+%28ICG%29+fluorescence+imaging+in+pediatric+minimally+invasive+surgery%5BTitle%5D)+AND+%22Pediatr+Surg+Int%22%5BJournal%5D)">Clinical application and technical standardization of indocyanine green (ICG) fluorescence imaging in pediatric minimally invasive surgery.</a> Pediatr Surg Int. 35 (10), 1043-1050 (2019).</li>
</ol>

作者声明不存在任何利益冲突。

腹腔镜胆囊切除术（LC）长期以来一直被视为治疗胆结石和胆囊炎的金标准。然而，在伴有急性炎症、坏疽、穿孔和解剖变异等情况下，传统手术方法常面临重大挑战，这些情况统称为困难胆囊16。这些复杂情况显著增加了胆管损伤（BDI）和胆囊动脉（CA）损伤的风险。
胆管损伤（BDI）是腹腔镜胆囊切除术（LC）中最严重的并发症之一，常由胆囊管（CD）与胆总管（CBD）的误判所致17。预防BDI的关键在于准确定位CD与CBD的汇合处，因此胆道系统的可视化至关重要。传统的术中可视化技术（IVT），如胆道造影、超声和胆道镜检查，最初正是为实现这一目的而开发的。然而，这些技术的应用受到辐射暴露风险、较高的误差率以及操作繁琐等因素的限制5,18。
近红外荧光（NIRF）是一种新开发的术中可视化技术（IVT），在多种肝胆外科手术中具有显著优势。这...

全球约有20%的成年人受胆道结石影响，这些结石可导致急性胆囊炎——一种疼痛剧烈、进展迅速且可能危及生命的疾病1。对于胆囊炎患者，及时进行外科手术干预至关重要。腹腔镜胆囊切除术（LC）已被广泛接受为该疾病的标准化治疗方法。
然而，传统外科手术方法在复杂病例中可能面临重大挑战。严重的炎症或粘连可导致胆道结构不清，增加胆管或动脉意外损伤的风险2。胆管损伤（BDI）是此类复杂腹腔镜胆囊切除术中最严重且最常见的并发症之一，常导致不可逆的终身后果，在严重情况下甚至可导致死亡3。准确识别关键胆道结构（如胆囊三角）对于顺利实施手术并最大限度减少潜在损伤至关重要4。
传统的术中可视化技术（IVT）结合了胆管造影、超声和胆道镜检查，可实现对胆道系统的实时监测。然而，由于存在辐射暴露、明显的误差率5以及操作繁琐等问题，IVT 的广泛应用受到限制。
近红外荧光（NIRF）是一种前沿技术，可通过单一腹腔镜在荧光模式与白光模式之间轻松切换，从而在手术过程中实现胆道系统的实时可视化。该技术具有高灵敏度、高特异性和良好的组织穿透能力6。NIRF 能有效预防腹腔镜胆囊切除术（LC）中的胆管损伤（BDI），尤其适用于伴有严重炎症或粘连的复杂病例7。
与传统的术中胆道造影（IVT）相比，近红外荧光成像（NIRF）更易于实施，能够更清晰地显示胆管结构，且不会造成额外创伤8,9,10。其所使用的荧光染料吲哚菁绿（ICG）已获得美国食品药品监督管理局（FDA）批准，证实其在人体应用中具有安全性11。ICG通常在手术前通过静脉注射给药；然而，其注射时机和剂量仍不明确12,13。这些因素是获得高质量荧光图像的关键决定因素。理想的ICG使用效果应在胆管中产生强烈的荧光信号，同时尽量减少来自肝组织的背景荧光14。
通过广泛探索，我们确定了吲哚菁绿（ICG）注射的最佳时机和剂量为术前45分钟给予0.25 mg。本研究旨在展示该时机和剂量在多种复杂手术场景中的成像效果。

<table><tbody><tr><td>3-0 MERSILK</td><td>JOHNSON MEDICAL (CHINA) LTD.&amp;nbsp;</td><td>SA84G</td><td>缝合材料</td></tr><tr><td>4-0 Coated VICRYL</td><td>ETHICON</td><td>VCP310</td><td>缝合材料</td></tr><tr><td>内窥镜荧光成像系统</td><td>ZHUHAI DI PU MEDICAL TECHNOLOGY CO., LTD.&amp;nbsp;</td><td>H380022041YF</td><td>荧光腹腔镜设备</td></tr><tr><td>Hem-O-lock 结扎夹</td><td>SINOLINKS MEDICAL INNOVOATION, INC.</td><td>B240714</td><td>Hem-O-lock 结扎夹</td></tr><tr><td>注射用吲哚菁绿</td><td>DANDONG YICHUANG PHARMACEUTICAL CO., LTD.&amp;nbsp;</td><td>H20055881</td><td>荧光染料</td></tr></tbody></table>

吲哚菁绿荧光在复杂腹腔镜胆囊切除术导航中的作用

The Role of Indocyanine Green Fluorescence in Complex Laparoscopic Cholecystectomy Navigation

腹腔镜胆囊切除术（LC）是胆石症和胆囊炎的金标准治疗方法。在伴有严重炎症和粘连的困难病例中，胆管损伤（BDI）的风险显著增高。准确识别胆道解剖结构对于预防此类损伤至关重要。传统的术中可视化技术（IVT）由于操作复杂、创伤较大且错误率较高，临床应用受到限制。近红外荧光（NIRF）成像技术以吲哚菁绿（ICG）作为荧光染料，已成为一种创新的术中可视化方法， increasingly 被认为是腹腔镜胆囊切除术中可行、安全且有效的技术。然而，NIRF在困难腹腔镜胆囊切除术中的有效性尚不明确，ICG给药的最佳时机和剂量也尚未确定。本文详细阐述了对一例急性坏疽性胆囊炎患者实施荧光引导下困难腹腔镜胆囊切除术的主要步骤，并评估了NIRF在不同情况下的成像效果。患者取仰卧位，放置四个穿刺套管。切换至荧光模式后，荧光标记的胆管结构清晰可见。在荧光引导下，谨慎解剖Calot三角，分别辨认出胆囊管（CD）和胆囊动脉（CA），夹闭后切除胆囊。最后，再次使用荧光模式检查手术区域，以排除胆漏。由于ICG成像效果满意且手术过程顺利，患者术后恢复良好。NIRF是一种安全有效的技术，在未来临床应用中具有广阔前景。

根据本方案中所述的手术步骤（图2），对三例胆囊情况复杂的患者成功实施了荧光引导下的腹腔镜胆囊切除术（LC）。手术过程中无一例转为开腹手术，亦未发生胆管损伤（BDI）。在荧光模式下未观察到胆汁渗漏，随附视频中已展示该结果。术中及术后结果总结于表1中。
2024年4月至8月期间，共记录了70例荧光引导下的腹腔镜胆囊切除术（LC）病例，人口统计学数据见表2。其中，91%（64/70）的病例获得了满意的荧光成像效果，所有胆管均清晰可见，胆道荧光信号强，且肝脏背景干扰最小。3例未能实现肝外胆管的荧光成像，原因是肝总管阻塞。此外，另有3例荧光成像效果欠佳：其中2例归因于吲哚菁绿（ICG）注射过早，1例为胆囊管（CD）阻塞所致。
手术过程中无一例中转开腹手术，无胆管损伤，且通过引流观察确认无术后胆汁渗漏。与传统的白光腹腔镜胆囊切除术（LC）相比，吲哚菁绿（ICG）荧光成像具有以下优势：（1）实现胆管的实时导航，增强...

本方案概述了荧光引导腹腔镜胆囊切除术的步骤，并阐明了荧光导航在多种外科手术场景中的作用。

腹腔镜胆囊切除术（LC）是治疗胆石症和胆囊炎的金标准。在伴有严重炎症等困难病例中，……

我们的研究涉及荧光成像在复杂腹腔镜胆囊切除术中的应用。本研究的主要目的是确定术前注射吲哚菁绿的最佳时机和剂量。复杂腹腔镜胆囊切除术的最新进展在于实现胆管结构的更佳可视化，例如我们目前正在研究的荧光成像技术。我们的研究已证实吲哚菁绿在复杂腹腔镜胆囊切除术中的应用价值，有助于术中更好地显示胆管结构。首先，在手术开始前45分钟，通过外周静脉注射向患者给予0.25毫克吲哚菁绿。设置DPMI荧光系统——一种双通道、影像引导设备——以同时在白光和近红外光谱下运行。现在，将患者仰卧位置于手术台上。按照机构批准的方案实施全身麻醉后，完成所有安全程序，包括佩戴头罩、无菌手套和无菌刷手服。建立无菌区域，并采用四通道法进行穿刺器插入。将DPMI荧光系统切换至荧光模式以定位胆管。在荧光导航下，使用电凝钩仔细分离并游离胆囊管和胆囊动脉，以获得安全的关键视野，即所谓的Calot三角。在识别并区分胆管后，使用Hem-O-lock夹闭合胆囊管以确保安全。切断胆囊管后，再切断胆囊动脉。接下来，使用适当的器械将胆囊从胆囊窝中分离。使用白光模式检查是否有出血。完成胆囊切除术后，切换至荧光模式以确认无胆汁渗漏。使用取物袋将胆囊从腹腔中取出。在胆囊窝处放置引流管。使用4-0聚乳酸羟基乙酸缝线缝合腹腔内层，皮肤则用3-0不可吸收缝线缝合。术后密切监测患者的恢复情况。进行相关检查以评估健康状况并检测任何异常。对三名患者成功实施了荧光引导腹腔镜胆囊切除术，术中无一例转为开腹手术，且未观察到胆管损伤。患者术后未出现胆汁渗漏、感染或腹痛等情况。

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吲哚菁绿荧光在复杂腹腔镜胆囊切除术导航中的作用

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