Laparoscopic Cholecystectomy with Indocyanine Green Fluorescence: Choledochoscopic Stone Extraction and Primary Duct Suture

Summary

The integrated technique described in this protocol achieves real-time biliary mapping via indocyanine green (ICG) fluorescence, minimally invasive stone clearance under direct visualization, and secure primary duct repair (6-0 PDS), eliminating T-tube drainage.

Abstract

This case report presents a fluorescence-guided laparoscopic cholecystectomy with common bile duct (CBD) exploration, fiberoptic choledochoscopic stone extraction, and primary duct closure. The patient was a 41-year-old male diagnosed with gallstones and secondary CBD stones. Intraoperatively, indocyanine green (ICG) fluorescence imaging was employed to delineate biliary anatomy precisely. Following cholecystectomy, the CBD was longitudinally incised, and stones were removed under choledochoscopic guidance. After confirming stone clearance and distal duct patency, the CBD was closed with an interrupted 6-0 polydioxanone suture (PDS) without T-tube drainage. The procedure lasted 196 min, with minimal blood loss (15 mL). No postoperative complications (e.g., bile leakage or stricture) occurred, and the patient was discharged on postoperative day 5. This case demonstrates that ICG-guided laparoscopy combined with choledochoscopy enables minimally invasive management of CBD stones, and primary suturing is a safe and feasible alternative to T-tube drainage, avoiding its associated complications in carefully selected patients with meticulous technique.

Introduction

Common bile duct (CBD) stones, a prevalent disorder of the biliary system, often originate from gallstones and may lead to serious complications such as biliary obstruction, cholangitis, or even pancreatitis. Traditional treatments include open or laparoscopic CBD exploration with stone extraction, routinely followed by T-tube drainage to reduce postoperative bile leakage and stricture risks. However, prolonged T-tube placement can cause patient discomfort, electrolyte imbalances, bile loss, and post-removal leakage. In recent years, with advancements in minimally invasive techniques, primary CBD closure has emerged as a promising alternative, offering advantages such as avoiding T-tube-related complications, shortening hospital stays, and accelerating recovery^1,2,3.

Fluorescence laparoscopy, utilizing indocyanine green (ICG) for real-time biliary tree imaging, enhances surgical precision and reduces bile duct injury risks^4,5. Additionally, fiberoptic choledochoscopy ensures complete stone clearance, providing a safety foundation for primary closure. This study presents a case of ICG-guided laparoscopic cholecystectomy with CBD exploration, stone extraction, and primary suturing, evaluating its feasibility and clinical value to advance minimally invasive management of CBD stones^6,7,8,9,10.

In this study, we systematically integrated three key techniques-ICG fluorescence imaging (for real-time biliary visualization), fiber optic choledochoscopy (for direct visual stone extraction), and primary duct closure with 6-0 PDS suture (eliminating T-tube drainage)-for the first time, establishing a standardized operational protocol^8,10.

Protocol

The surgical procedure was performed in accordance with the operative protocol approved by the Ethics Committee of Guangzhou First People's Hospital (Ethics Approval Number: B-2022-031-01), and written informed consent was obtained from the patient. All procedures complied with the principles of the Declaration of Helsinki.

1. Preoperative preparation

1. Patient preparation
   1. Confirm the patient has fasted for 8 h and abstained from fluids for 2 h preoperatively. Establish two intravenous access lines.
   2. Administer 2.5 mg of indocyanine green (ICG) intravenously approximately 20 min before anesthesia induction.
      CAUTION: ICG may cause allergic reactions. Ensure emergency equipment is readily available.
      NOTE: Allow 15-20 min after ICG injection for optimal imaging enhancement^11,12,13.
2. Equipment preparation
   1. Activate the fluorescence laparoscopy system. Adjust the switching function between white light and fluorescence modes. Verify light source intensity and camera focus.
   2. Prepare 5-mm and 12-mm trocars, a laparoscopic instrument set, fiberoptic choledochoscopy system, stone retrieval basket, and ultrasonic scalpel.
   3. Ensure the suction/irrigation system is patent. Prepare 6-0 polydioxanone suture (PDS) sutures and laparoscopic needle holders.

2. Surgical procedure

1. Pneumoperitoneum establishment and trocar placement
   1. Make a 12 mm infraumbilical incision. Insert the first 12-mm Trocar using the open technique. Establish CO₂ pneumoperitoneum, maintaining pressure at 12 mmHg.
   2. Under laparoscopic guidance, place four additional Trocars: epigastric region, right midclavicular line subcostal, right anterior axillary line subcostal (all 5 mm Trocars), and left paramedian point midway between xiphoid and umbilicus (12 mm Trocar). Figure 1 shows trocar placement.
2. Cholecystectomy
   1. Press the camera mode (M) button once to switch to color fluorescence mode. Adjust the gain to 50%-60%. Observe the structures of the Calot's triangle. Confirm the fluorescence imaging of the cystic duct, common hepatic duct, and common bile duct. Figure 2 offers an intraoperative view of the critical structures within Calot's triangle.
   2. Dissect Calot's triangle. Isolate the cystic artery, doubly clip it with 5 mm hemoclips, then transect. Figure 3 delineates the anatomical relationship between the cystic duct and the common bile duct.
   3. Free the cystic duct until ~1.0 cm from its junction with the CBD. Apply clips but defer transection.
   4. Dissect the gallbladder from its bed with electrocautery hemostasis.
3. CBD exploration
   1. Mobilize the serosa overlying the planned CBD incision site to expose the duct course. Figure 4 illustrates the synergistic integration of four imaging modalities.
   2. Make a 0.8 cm longitudinal choledochotomy using laparoscopic scissors. Preserve adequate duct wall for subsequent closure.
   3. Insert a 3 mm choledochoscope via the epigastric port to examine the CBD and intrahepatic ducts.
   4. Retrieve identified stones completely using a retrieval basket. Irrigate repeatedly to confirm clearance.
   5. Inspect the distal CBD to verify patency of the sphincter of Oddi. Figure 5 shows the operative field during ICG-guided common bile duct exploration.
4. Primary CBD closure
   1. Suture the choledochotomy with interrupted 6-0 PDS stitches:
      1. Begin at the distal incision margin.
      2. Maintain 2 mm stitch intervals and 1 mm edge margins. Figure 6 demonstrates the key steps involved in the primary suturing technique of the common bile duct.
   2. After complete suturing:
      1. Transect the cystic duct.
      2. Temporarily position the gallbladder on the right hepatic lobe.
      3. Verify bile flow from the cystic duct stump and absence of residual stones.
      4. Perform a saline leak test via the cystic duct stump. Figure 7 offers an intraoperative view of the cystic duct stump as a critical structure.
   3. Place a closed-suction drain in Winslow's foramen, exteriorized through the right anterior axillary port.
5. Procedure completion
   1. Extract the gallbladder in an endobag via the umbilical port.
   2. Release the pneumoperitoneum. Close the 12 mm port sites in layers; suture only the skin for 5 mm ports.

3. Postoperative management

1. Immediate care
   1. Document operative duration, blood loss, and fluid balance (Table 1).
   2. Submit gallbladder and stones for pathological examination.
2. Monitoring
   1. Assess drain output: Remove the drain if output is <30 mL/24 h without bile.
   2. On postoperative day 1, check liver function tests, complete blood count, and CRP levels (Table 2).
   3. This procedure is indicated for patients with a common bile duct diameter ≥8 mm, no more than 3 stones, and without acute cholangitis. The general condition of the patient in this case met the criteria for primary anterior wall closure of the common bile duct, as detailed in Table 3. Conversion to T-tube drainage should be implemented if intraoperative signs of cholangitis or excessive suture tension are identified¹⁴.

Results

This case demonstrates the successful application of fluorescence laparoscopy (ICG imaging) combined with fiberoptic choledochoscopy for cholecystectomy and common bile duct (CBD) exploration with stone extraction, followed by primary closure of the CBD anterior wall using 6-0 PDS sutures without T-tube placement. The findings further verified that primary closure of the common bile duct is safe and feasible when specific criteria are met (e.g., in patients with a common bile duct diamete...

Discussion

This case utilized indocyanine green (ICG) fluorescence imaging technology, enabling real-time and precise visualization of biliary anatomy, thereby reducing the risk of iatrogenic injury. This technique proves particularly valuable in cases with difficult dissection of Calot's triangle or inflammatory adhesions^6,7,8,15,16. Compared to conventional laparos...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
6-0 PDS II Suture	Ethicon Endo-Surgery (China) Co., Ltd.	China Medical Device Import Registration Certificate No. 20153132234	6-0 PDS sutures are commonly used in ophthalmic and microvascular surgeries.
Abdominal Trocar	Ethicon Endo-Surgery, LLC	China Medical Device Import Registration Certificate No. 20152023388	Intraoperative use of three 5-mm trocars and two 12-mm trocars.
Disposable Electronic Choledochoscopy Imaging Catheter	Guangzhou Ruipai Medical Devices Co., Ltd.	Guangdong Medical Device Registration Certificate No. 2023060646	The disposable electronic choledochoscopy imaging catheter must be used in conjunction with an endoscopy processor.
Hem-o-lok Clip	Aidier (Xiamen) Medical Devices Co., Ltd.	China Medical Device Registration Certificate No. 20233021658	For surgical closure of tubular structures; not intended for major arteries or veins.
Indocyanine Green for Injection	Dandong Yichuang Pharmaceutical Co., Ltd.	Chinese Drug Approval No. H20055881	This medication is a diagnostic dye, mainly used for fluorescence imaging in cardiovascular, hepatic, and ophthalmic diagnostics.
Nitinol Tipless Stone Extractor	Cook Medical Europe LTD	REF: NTSE-045065-UDH REF: G17520	Nitinol Tipless Stone Extractor. For removal of calculi under endoscopic guidance. Single-use device. Sterile unless package is opened or damaged.
OptoMedic 2100 Series HD fluorescence endoscopic system	Guangzhou OptoMedic Technologies Inc, Guangzhou, China	2100 Series HD	OptoMedic fluorescence endoscopic system for real-time ICG-guided surgery (e.g., tumor resection, lymphatic mapping).
SOUND REACH Ultrasonic Scalpel System	Tianjin Rich Medical Instruments Co., Ltd.	China Medical Device Registration Certificate No. 20213010924	Ultrasonic Soft Tissue Cutting and Hemostasis System?Disposable Ultrasonic Scalpel Blade.