Laparoscopic Cholecystectomy with Indocyanine Green Fluorescence: Choledochoscopic Stone Extraction and Primary Duct Suture
November 25th, 2025
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.
This research aims to optimize a minimally invasive protocol for safely removing common bile duct stones and achieving primary duct closure. A combination of fluorescence cholangiography and choledochoscopy for precise stone extraction is being used in the field currently. To begin, make the required infraumbilical incision and insert the first 12-millimeter trocar using the open technique.
Under laparoscopic guidance, place four additional trocars, one in the epigastric region, one in the right midclavicular line subcostal, one in the right anterior axillary line subcostal, and one in the left paramedian point, midway between the xiphoid and umbilicus. Press the camera mode and button once to switch to color fluorescence mode. Adjust the gain to 50%to 60%Observe the structures of Calot's triangle and confirm the fluorescence imaging of the cystic duct, common hepatic duct, and common bile duct.
Then dissect Calot's triangle. Isolate the cystic artery, doubly clip it with 5-millimeter hemoclips, and then transect the artery. Free the cystic duct until approximately 1 centimeter from its junction with the common bile duct.
Dissect the gallbladder from its bed using electrocautery while ensuring hemostasis. Now, mobilize the serosa overlying the planned common bile duct incision site to expose the duct course. Then make a 0.8-centimeter longitudinal choledochotomy using laparoscopic scissors and preserve adequate duct wall for subsequent closure.
Insert a 3-millimeter choledochoscope via the epigastric port to examine the common bile duct and intrahepatic ducts. Now, begin suturing at the distal incision margin. Maintain 2-millimeter stitch intervals and 1-millimeter edge margins during suturing.
After completing the primary suture, transect the cystic duct carefully. Verify bile flow from the cystic duct stump and confirm absence of residual stones. Finally, place a closed suction drain in Winslow's foramen and exteriorize it through the right anterior axillary port.
Indocyanine green fluorescence clearly delineated the cystic duct, the common bile duct, and the common hepatic duct, supporting precise anatomical localization. The procedure was completed in 196 minutes with minimal blood loss of 15 milliliters. The patient was discharged on postoperative day five with a satisfactory recovery status at follow-up.
No postoperative bile leakage or stricture was observed, as reflected by the absence of complications. This technique's main advantage is avoiding a T-tube, which promotes faster recovery and improves patient's quality of life. This protocol provides a new standard for safe, efficient, primary duct closure, advancing minimally invasive biliary surgery.
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Overview
This protocol presents an integrated technique for real-time biliary mapping using indocyanine green (ICG) fluorescence, facilitating minimally invasive stone clearance and secure primary duct repair.
Key Study Components
Area of Science
- Minimally invasive surgery
- Fluorescence imaging
- Biliary tract procedures
Background
- Common bile duct stones pose significant surgical challenges.
- Traditional methods often require T-tube drainage.
- Fluorescence cholangiography enhances visualization during surgery.
- Direct visualization techniques improve outcomes in biliary surgery.
Purpose of Study
- To optimize a minimally invasive protocol for stone removal.
- To achieve primary duct closure without the need for T-tube drainage.
- To utilize fluorescence imaging for precise surgical navigation.
Methods Used
- Infraumbilical incision for trocar placement.
- Use of multiple trocars for laparoscopic access.
- Color fluorescence mode for imaging biliary structures.
- Adjusting imaging gain for optimal visualization.
Main Results
- Successful real-time biliary mapping achieved.
- Minimally invasive stone clearance demonstrated.
- Primary duct repair completed without T-tube drainage.
- Enhanced visualization of biliary anatomy confirmed.
Conclusions
- The integrated technique improves surgical outcomes.
- Fluorescence imaging is effective for biliary procedures.
- This protocol may reduce complications associated with traditional methods.
Frequently Asked Questions
Executive Industry Relevance
Fluorescence-guided laparoscopic cholecystectomy with choledochoscopic stone extraction and primary duct suture exemplifies the integration of advanced imaging and minimally invasive techniques for precise biliary intervention. Real-time indocyanine green (ICG) fluorescence mapping enhances anatomical clarity, supporting safer ductal manipulation and reducing procedural risk. This protocol advances the standard for intraoperative decision-making and workflow efficiency in complex biliary procedures.
Strategic Applications in Biopharma R&D
Early Discovery & Target Validation
- Enables precise anatomical localization for hypothesis-driven surgical modeling.
- Supports mechanistic de-risking by directly visualizing ductal structures and intervention outcomes.
- Facilitates functional validation of imaging agents and device-assisted workflows.
Screening & Assay Development
- Provides a validated system for evaluating fluorescence imaging agents in live tissue contexts.
- Standardizes intraoperative imaging parameters for reproducible quantitative assessment.
- Enables benchmarking of device performance and imaging-guided intervention protocols.
Translational & Preclinical Research
- Aligns with translational goals by modeling clinically relevant, minimally invasive interventions.
- Supports continuity from imaging agent discovery to preclinical validation in surgical settings.
- Reduces translational risk by demonstrating workflow feasibility and safety endpoints.
Pipeline & Workflow Integration
This protocol bridges discovery-stage imaging agent validation with preclinical modeling of surgical workflows, supporting the continuum from early discovery to translational research.
- Discovery Biology: Advances hypothesis testing for imaging agent specificity and ductal visualization.
- Screening: Establishes reproducible imaging and procedural benchmarks for candidate evaluation.
- Analytics: Delivers quantitative outputs on anatomical delineation, procedural safety, and intervention success.
- Translational Research: Demonstrates preclinical feasibility of fluorescence-guided interventions in disease-relevant models.
- Enterprise Reuse: Provides a modular workflow adaptable to diverse imaging agents and surgical platforms.
Operational & Enterprise Impact
- Scientific Value: Increases predictive confidence in imaging agent performance and procedural safety.
- Operational Value: Standardizes imaging and intervention protocols for reproducibility and scalability.
- Strategic Value: Informs go/no-go decisions for imaging agent and device development pipelines.
- Portfolio Impact: Enables risk-adjusted prioritization of translational imaging and surgical innovation projects.
Implementation Considerations
- Requires expertise in laparoscopic surgery and intraoperative imaging interpretation.
- Demands access to fluorescence-capable laparoscopic systems and choledochoscopic instrumentation.
- Necessitates cross-team standardization of imaging parameters and procedural steps.
- Adaptation across preclinical models may require protocol optimization for anatomical differences.
- Careful patient or model selection is critical to minimize procedural risk and ensure data relevance.
