Real-Time Indocyanine Green Fluorescence Navigation in Difficult Laparoscopic Cholecystectomy

Summary

This protocol describes real-time indocyanine green fluorescence navigation for laparoscopic cholecystectomy, a safe, effective, and minimally invasive approach particularly suitable for difficult cases.

Abstract

Laparoscopic cholecystectomy (LC), with its advantages of minimal invasiveness and rapid recovery, has become the standard surgical approach for benign gallbladder diseases. However, even experienced surgeons cannot completely avoid bile duct injury (BDI), and the incidence of BDI during LC is 2-3 times higher than that of open surgery, making it the most common cause of iatrogenic BDI. Approximately 20% of BDIs require multiple surgeries, and about 0.8% eventually result in liver transplantation, significantly impacting patient safety and quality of life, while posing a major risk for medical disputes. Achieving real-time intraoperative visualization is crucial to preventing BDI, particularly in difficult cholecystectomy cases under inflammatory conditions. Real-time indocyanine green (ICG) fluorescence guidance during LC can enhance extrahepatic bile duct visualization and minimize the risk of bile duct injury. In this surgical protocol, an 83-year-old female patient, who had undergone percutaneous transhepatic gallbladder drainage (PTGBD) for acute suppurative cholecystitis 6 weeks prior, was admitted for LC. During the operation, 2.5 mg of ICG was intravenously administered 10 min before the skin incision. Twenty minutes after injection, the liver and common bile duct were clearly visualized under fluorescence imaging. As the dissection of Calot's triangle progressed, the gallbladder and cystic duct remained unstained due to stone impaction, creating a stark visual contrast. Under dynamic ICG guidance, Calot's triangle was meticulously dissected, and the cystic artery and cystic duct were sequentially ligated and divided. The gallbladder was successfully removed. The surgical field showed no bleeding, and fluorescence imaging confirmed no bile leakage, achieving visualized LC under severe inflammatory adhesions. The patient was discharged on the third postoperative day. Real-time ICG fluorescence navigation for LC is safe, effective, and minimally invasive, particularly suitable for difficult cases.

Introduction

Since German surgeon Langenbuch performed the first cholecystectomy in 1882, this procedure has become one of the most common operations in hepatobiliary surgery. With the completion of the first laparoscopic cholecystectomy (LC) by German surgeon Erich Mühe in 1985, LC has now become the standard surgical approach for benign gallbladder diseases¹. Advances in diagnostic techniques and medical equipment have driven the evolution of LC from multiport, 2D, and standard-definition systems toward single-port, 3D, and 4K high-definition systems, further enhancing its safety. Nevertheless, the incidence of bile duct injury (BDI) during LC remain....

Protocol

This protocol follows the guidelines of the Human Research Ethics Committee of The First Affiliated Hospital of Guangzhou Medical University. Informed consent was obtained from the patients for the release of information and data related to this treatment. The reagents and equipment used are listed in the Table of Materials.

1. Patient selection

1. Use the following inclusion criteria
   1. Perform LC navigated by real-time indocyanine green fluorescence in patients with gallstones accompanied by acute or chronic cholecystitis or benign gallbladder diseases with a history of abdominal surgery....

Results

The baseline characteristics and intraoperative parameters are summarized in Supplementary Table 1. The operative outcomes are summarized in Table 1. The total operative time was 90 min, with an estimated blood loss of 10 mL and urine output of 150 mL. The nasogastric tube was removed immediately after surgery. On postoperative day (POD) 1, the urinary catheter was removed. By POD 2, the abdominal drain was removed after collecting 10 mL of clear yellow fluid without evidence of blood or.......

Discussion

LC is the most commonly used surgical approach for treating benign gallbladder diseases. However, LC carries the risk of BDI, particularly in cases of acute gallbladder inflammation or a history of upper abdominal surgery¹⁴. Visualizing the anatomy of the extrahepatic bile ducts is a key method to avoid BDI.ICG can assist in fluorescence imaging of the extrahepatic bile ducts.ICG is a dark green-blue dye from the tricarbocyanine family, with minimal toxicity and few adverse effects. After intraven.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Electrosurgical Generator	COVIDIEN	Force FX-8c	For blood vessel coagulation and division
ETHICON ENDOPATH  XCEL 5 mm Trocar	ETHICON	5XLT100	Provides secure, minimally invasive peritoneal access for instrument introduction during laparoscopic surgery.
ETHICON ENDOPATH XCEL 12 mm Trocar	ETHICON	12XLT100	Provides secure, minimally invasive peritoneal access for instrument introduction during laparoscopic surgery.
Fluorescence Endoscopic System(PINPOINT)	Stryker	SC9134	An endoscopic camera system wit 4K fluorescence imaging
Harmonic Scalpel	Ethicon Endo-Surgery	GEN11	For blood vessel coagulation and division
HEM-O-LOK Polymer Clip	ETHICON	544950	provide hemostasis and vessel or duct closure during laparoscopic procedures.
Indocyanine Green for Injection	Dandong Yichuang Pharmaceutical	H20055881	Intraoperative fluorescence imaging
SPSS 25.0			statistical analysis software