Name: Laparoscopic Cholecystectomy with Indocyanine Green Fluorescence: Choledochoscopic Stone Extraction and Primary Duct Suture (Video) | JoVE Journal
Uploaded: 2025-11-25T14:00:00.000+00:00
Duration: 4 min 2 s
Description: Learn minimally invasive stone removal and primary duct closure using ICG fluorescence cholangiography and choledochoscopy. This technique avoids T-tube drainage and promotes faster patient recovery.

ai_agent_IP

ai_agent

maintenance

instantTrialDurationMinutes

isBiopharma

enableNewMyJoveSectionDesign

educationFeatures

seoMetaApi

ai_copilot_institution_blacklist

ai_chat_institution_blacklist

freeAccessWindow

ssoRoleCapture

scheduledMaintenanceBanner

joveLabsFeatures

disable_autoplay_for_bots

extended_trial_duration

5 minutes

We would like to express our gratitude to all staff members who contributed to this work.

The surgical procedure was performed in accordance with the operative protocol approved by the Ethics Committee of Guangzhou First People&#39;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
<ol>
	<li>Patient preparation
	<ol>
		<li>Confirm the patient has fasted for 8 h and abstained from fluids for 2 h preoperatively. Establish two intravenous access lines.</li>
		<li>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 enhancement11,12,13.</li>
	</ol>
	</li>
	<li>Equipment preparation
	<ol>
		<li>Activate the fluorescence laparoscopy system. Adjust the switching function between white light and fluorescence modes. Verify light source intensity and camera focus.</li>
		<li>Prepare 5-mm and 12-mm trocars, a laparoscopic instrument set, fiberoptic choledochoscopy system, stone retrieval basket, and ultrasonic scalpel.</li>
		<li>Ensure the suction/irrigation system is patent. Prepare 6-0 polydioxanone suture (PDS) sutures and laparoscopic needle holders.</li>
	</ol>
	</li>
</ol>
2. Surgical procedure
<ol>
	<li>Pneumoperitoneum establishment and trocar placement
	<ol>
		<li>Make a 12 mm infraumbilical incision. Insert the first 12-mm Trocar using the open technique. Establish CO2&#160;pneumoperitoneum, maintaining pressure at 12 mmHg.</li>
		<li>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.</li>
	</ol>
	</li>
	<li>Cholecystectomy
	<ol>
		<li>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&#39;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&#39;s triangle.</li>
		<li>Dissect Calot&#39;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.</li>
		<li>Free the cystic duct until ~1.0 cm from its junction with the CBD. Apply clips but defer transection.</li>
		<li>Dissect the gallbladder from its bed with electrocautery hemostasis.</li>
	</ol>
	</li>
	<li>CBD exploration
	<ol>
		<li>Mobilize the serosa overlying the planned CBD incision site to expose the duct course. Figure 4 illustrates the synergistic integration of four imaging modalities.</li>
		<li>Make a 0.8 cm longitudinal choledochotomy using laparoscopic scissors. Preserve adequate duct wall for subsequent closure.</li>
		<li>Insert a 3 mm choledochoscope via the epigastric port to examine the CBD and intrahepatic ducts.</li>
		<li>Retrieve identified stones completely using a retrieval basket. Irrigate repeatedly to confirm clearance.</li>
		<li>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.</li>
	</ol>
	</li>
	<li>Primary CBD closure
	<ol>
		<li>Suture the choledochotomy with interrupted 6-0 PDS stitches:
		<ol>
			<li>Begin at the distal incision margin.</li>
			<li>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.</li>
		</ol>
		</li>
		<li>After complete suturing:
		<ol>
			<li>Transect the cystic duct.</li>
			<li>Temporarily position the gallbladder on the right hepatic lobe.</li>
			<li>Verify bile flow from the cystic duct stump and absence of residual stones.</li>
			<li>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.</li>
		</ol>
		</li>
		<li>Place a closed-suction drain in Winslow&#39;s foramen, exteriorized through the right anterior axillary port.</li>
	</ol>
	</li>
	<li>Procedure completion
	<ol>
		<li>Extract the gallbladder in an endobag via the umbilical port.</li>
		<li>Release the pneumoperitoneum. Close the 12 mm port sites in layers; suture only the skin for 5 mm ports.</li>
	</ol>
	</li>
</ol>
3. Postoperative management
<ol>
	<li>Immediate care
	<ol>
		<li>Document operative duration, blood loss, and fluid balance (Table 1).</li>
		<li>Submit gallbladder and stones for pathological examination.</li>
	</ol>
	</li>
	<li>Monitoring
	<ol>
		<li>Assess drain output: Remove the drain if output is &#60;30 mL/24 h without bile.</li>
		<li>On postoperative day 1, check liver function tests, complete blood count, and CRP levels (Table 2).</li>
		<li>This procedure is indicated for patients with a common bile duct diameter &#8805;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.</li>
	</ol>
	</li>
</ol>

<ol><li>Zhuang, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+comparison+of+the+therapeutic+outcomes+between+primary+duct+closure+and+T-tube+drainage+after+laparoscopic+common+bile+duct+exploration%3A+a+single-centre+retrospective+study%5BTitle%5D)+AND+%22Wideochir+Inne+Tech+Maloinwazyjne%22%5BJournal%5D)">A comparison of the therapeutic outcomes between primary duct closure and T-tube drainage after laparoscopic common bile duct exploration: a single-centre retrospective study.</a> Wideochir Inne Tech Maloinwazyjne. 18 (1), 108-116 (2023).</li>
<li>Xiang, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Safety+and+feasibility+of+primary+closure+following+laparoscopic+common+bile+duct+exploration+for+treatment+of+choledocholithiasis%5BTitle%5D)+AND+%22World+J+Surg%22%5BJournal%5D)">Safety and feasibility of primary closure following laparoscopic common bile duct exploration for treatment of choledocholithiasis.</a> World J Surg. 47 (4), 1023-1030 (2023).</li>
<li>Gomez, D. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Long-term+outcomes+of+laparoscopic+common+bile+duct+exploration+through+diathermy%2C+choledochotomy%2C+and+primary+closure%3A+A+6-year+retrospective+cohort+study%5BTitle%5D)+AND+%22J+Laparoendosc+Adv+Surg+Tech+A%22%5BJournal%5D)">Long-term outcomes of laparoscopic common bile duct exploration through diathermy, choledochotomy, and primary closure: A 6-year retrospective cohort study.</a> J Laparoendosc Adv Surg Tech A. 33 (3), 281-286 (2023).</li>
<li>Zhidong, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Indocyanine+green+for+targeted+imaging+of+the+gall+bladder+and+fluorescence+navigation%5BTitle%5D)+AND+%22J+Biophotonics%22%5BJournal%5D)">Indocyanine green for targeted imaging of the gall bladder and fluorescence navigation.</a> J Biophotonics. 15 (11), e202200142(2022).</li>
<li>Antonio, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Near-infrared+fluorescent+cholangiography+-+real-time+visualization+of+the+biliary+tree+during+elective+laparoscopic+cholecystectomy%5BTitle%5D)+AND+%22HPB+%28Oxford%29%22%5BJournal%5D)">Near-infrared fluorescent cholangiography - real-time visualization of the biliary tree during elective laparoscopic cholecystectomy.</a> HPB (Oxford). 20 (6), 538-545 (2018).</li>
<li>Wang, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Clinical+application+of+indocyanine+green+fluorescence+navigation+technique+in+laparoscopic+common+bile+duct+exploration+for+complex+hepatolithiasis%5BTitle%5D)+AND+%22BMC+Surg%22%5BJournal%5D)">Clinical application of indocyanine green fluorescence navigation technique in laparoscopic common bile duct exploration for complex hepatolithiasis.</a> BMC Surg. 24 (1), 117(2024).</li>
<li>Zhou, H., He, Y., Chang, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparative+study+of+Indocyanine+Green+fluorescence+imaging+versus+conventional+fiber-optic+imaging+in+laparoscopic+choledochotomy+for+stone+extraction+and+immediate+biliary+incision+suturing%5BTitle%5D)+AND+%22Updates+Surg%22%5BJournal%5D)">Comparative study of Indocyanine Green fluorescence imaging versus conventional fiber-optic imaging in laparoscopic choledochotomy for stone extraction and immediate biliary incision suturing.</a> Updates Surg. 76 (6), 2247-2254 (2024).</li>
<li>Wang, Z. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Clinical+application+of+indocyanine+green+fluorescence+imaging+in+laparoscopic+cholecystectomy+with+common+bile+duct+exploration+and+J-Tube+drainage%5BTitle%5D)+AND+%22World+J+Gastrointest+Surg%22%5BJournal%5D)">Clinical application of indocyanine green fluorescence imaging in laparoscopic cholecystectomy with common bile duct exploration and J-Tube drainage.</a> World J Gastrointest Surg. 17 (1), 99495(2025).</li>
<li>Lu, J., Zhang, X., Zeng, C., Gu, J. T., Cai, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Clinical+Analysis+of+laparoscopic+common+bile+duct+primary+suture+and+T-tube+drainage+in+the+treatment+of+common+bile+duct+stones%5BTitle%5D)+AND+%22J+Laparoendosc+Adv+Surg+Tech+A%22%5BJournal%5D)">Clinical Analysis of laparoscopic common bile duct primary suture and T-tube drainage in the treatment of common bile duct stones.</a> J Laparoendosc Adv Surg Tech A. 33 (7), 622-625 (2023).</li>
<li>Padilla Zegarra, E. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Primary+choledochorraphy+after+laparoscopic+common+bile+duct+exploration%3A+comparative+study+of+3+different+methods%2C+safety%2C+and+efficacy%5BTitle%5D)+AND+%22J+Gastrointest+Surg%22%5BJournal%5D)">Primary choledochorraphy after laparoscopic common bile duct exploration: comparative study of 3 different methods, safety, and efficacy.</a> J Gastrointest Surg. 29 (9), 102122(2025).</li>
<li>Qiangxing, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Extrahepatic+biliary+tract+visualization+using+near-infrared+fluorescence+imaging+with+indocyanine+green%3A+optimization+of+dose+and+dosing+time%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Extrahepatic biliary tract visualization using near-infrared fluorescence imaging with indocyanine green: optimization of dose and dosing time.</a> Surg Endosc. 35 (10), 5573-5582 (2020).</li>
<li>Yu, H., 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 (2022).</li>
<li>Hui, L., 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>Deng, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Greater+than+or+equal+to+8+mm+is+a+safe+diameter+of+common+bile+duct+for+primary+duct+closure%3A+single-arm+meta-analysis+and+systematic+review%5BTitle%5D)+AND+%22Clin+J+Gastroenterol%22%5BJournal%5D)">Greater than or equal to 8 mm is a safe diameter of common bile duct for primary duct closure: single-arm meta-analysis and systematic review.</a> Clin J Gastroenterol. 15 (3), 513-521 (2022).</li>
<li>You, J., Jun, L., Wenbo, L., Jun, Z., Liang, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Primary+closure+after+laparoscopic+common+bile+duct+exploration+is+safe+and+feasible+for+patients+with+non-severe+acute+cholangitis%5BTitle%5D)+AND+%22Langenbecks+Arch+Surg%22%5BJournal%5D)">Primary closure after laparoscopic common bile duct exploration is safe and feasible for patients with non-severe acute cholangitis.</a> Langenbecks Arch Surg. 407 (4), 1553-1560 (2022).</li>
<li>Sioh Huang, L., Hui Ting Alyssa, T., Vishal, G. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparison+of+indocyanine+green+dye+fluorescent+cholangiography+with+intra-operative+cholangiography+in+laparoscopic+cholecystectomy%3A+a+meta-analysis%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Comparison of indocyanine green dye fluorescent cholangiography with intra-operative cholangiography in laparoscopic cholecystectomy: a meta-analysis.</a> Surg Endosc. 35 (4), 1511-1520 (2021).</li>
<li>Dragos, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Systematic+review+of+the+role+of+indocyanine+green+near-infrared+fluorescence+in+safe+laparoscopic+cholecystectomy+%28Review%29%5BTitle%5D)+AND+%22Exp+Ther+Med%22%5BJournal%5D)">Systematic review of the role of indocyanine green near-infrared fluorescence in safe laparoscopic cholecystectomy (Review).</a> Exp Ther Med. 23 (2), 187(2022).</li>
<li>Hendry, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Efficacy+and+safety+of+near-infrared+florescence+cholangiography+using+indocyanine+green+in+laparoscopic+cholecystectomy%3A+A+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22J+Laparoendosc+Adv+Surg+Tech+A%22%5BJournal%5D)">Efficacy and safety of near-infrared florescence cholangiography using indocyanine green in laparoscopic cholecystectomy: A systematic review and meta-analysis.</a> J Laparoendosc Adv Surg Tech A. 33 (5), 434-446 (2022).</li>
<li>Zhan, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Primary+closure+with+self-disengaging+biliary+stent+following+laparoscopic+CBD+exploration+in+normal-diameter+ducts%3A+a+propensity+score+matching+study%5BTitle%5D)+AND+%22Sci+Rep%22%5BJournal%5D)">Primary closure with self-disengaging biliary stent following laparoscopic CBD exploration in normal-diameter ducts: a propensity score matching study.</a> Sci Rep. 15 (1), 19959(1995).</li>
<li>Taifeng, Z., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+clinical+effect+of+primary+duct+closure+and+T-tube+drainage%3A+A+propensity+score+matched+study%5BTitle%5D)+AND+%22Asian+J+Surg%22%5BJournal%5D)">The clinical effect of primary duct closure and T-tube drainage: A propensity score matched study.</a> Asian J Surg. 46 (8), 3046-3051 (2022).</li>
<li>Becq, A., Soualy, A., Camus, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Cholangioscopy+for+biliary+diseases%5BTitle%5D)+AND+%22Curr+Opin+Gastroenterol%22%5BJournal%5D)">Cholangioscopy for biliary diseases.</a> Curr Opin Gastroenterol. 39 (2), 67-74 (2023).</li>
<li>Mauro, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+role+of+cholangioscopy+in+biliary+diseases%5BTitle%5D)+AND+%22Diagnostics+%28Basel%29%22%5BJournal%5D)">The role of cholangioscopy in biliary diseases.</a> Diagnostics (Basel). 13 (18), 2933(2023).</li>
<li>SU, S. -K., Zhou, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+effect+of+laparoscopy+combined+with+choledochoscopy+and+selective+duodenoscopy+in+the+treatment+of+cholecystolithiasis+complicated+with+choledocholithiasis%5BTitle%5D)+AND+%22Chinese+Journal+of+Modern+Operative+Surgery%22%5BJournal%5D)">The effect of laparoscopy combined with choledochoscopy and selective duodenoscopy in the treatment of cholecystolithiasis complicated with choledocholithiasis.</a> Chinese Journal of Modern Operative Surgery. 22 (2), 109-112 (2018).</li>
</ol>

The authors declare no conflicts of interest. No potential conflicts of interest were declared with respect to the device manufacturers mentioned in this study.

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&#39;s triangle or inflammatory adhesions6,7,8,15,16. Compared to conventional laparos...

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 recovery1,2,3.
Fluorescence laparoscopy, utilizing indocyanine green (ICG) for real-time biliary tree imaging, enhances surgical precision and reduces bile duct injury risks4,5. 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 stones6,7,8,9,10.
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 protocol8,10.

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

laparoscopic cholecystectomy with indocyanine green fluorescence: choledochoscopic stone extraction and primary duct suture

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

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.

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...

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 case report presents a fluorescence-guided laparoscopic cholecystectomy with common bile duct (CBD) exploration, fiberoptic choledochoscopic stone ...

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.

laparoscopic-cholecystectomy-with-indocyanine-green-fluorescence

Research

JoVE Journal

Medicine

Here, we develop and present a T-tube and intrabiliary stent-free technique utilizing dual-lens visualization (via laparoscope and choledochoscope) combined with laparoscopic ultrasonography (LUS) to perform primary choledochal suture.

Application of Laparoscopic Ultrasonography in Primary Choledochal Suture during Combined Two-lens Surgery

Cholecystolithiasis with common bile duct stones is a common disease; however, traditional common bile duct exploration has its own limitations. We propose a modified micro incision for laparoscopic common bile duct exploration aimed at reducing complication rates.

Laparoscopic Common Bile Duct Exploration Followed by Primary Suture Using a Modified Bile Duct Incision

This protocol outlines the steps for fluorescence-guided laparoscopic cholecystectomy and elucidates the role of fluorescence navigation in diverse surgical scenarios.

The Role of Indocyanine Green Fluorescence in Complex Laparoscopic Cholecystectomy Navigation

Indocyanine Green Angiography (or ICGA) performed by tail vein injection provides high quality ICGA time course images to characterize abnormalities in mouse choroid.

Detecting Abnormalities in Choroidal Vasculature in a Mouse Model of Age-related Macular Degeneration by Time-course Indocyanine Green Angiography

The goal of this protocol is to present transcanalicular laser-assisted dacryocystorhinostomy as a minimally invasive approach in the treatment of primary acquired nasolacrimal duct obstruction.

Transcanalicular Diode Laser-assisted Dacryocystorhinostomy for the Treatment of Primary Acquired Nasolacrimal Duct Obstruction

This protocol presents an improved method to obtain transient myocardial hypertrophy with absorbable suture, simulating left ventricular hypertrophy decrease after removing pressure overload. It could be valuable for the studies on myocardial hypertrophic preconditioning.

Operating Transverse Aortic Constriction with Absorbable Suture to Obtain Transient Myocardial Hypertrophy

This "two-step method" significantly improved the success rate of percutaneous transhepatic choledochoscopy and achieved a better prognosis of intrahepatic and extrahepatic choledocholithiasis.

A Two-Step Method for Percutaneous Transhepatic Choledochoscopic Lithotomy

This protocol presents Indocyanine Green-guided video-assisted retroperitoneal debridement (ICG-guided VARD) for treating severe acute necrotizing pancreatitis.

Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating Acute Necrotizing Pancreatitis

Robotic liver surgery has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. However, robotic left hepatectomy is still technically demanding. We describe our surgical technique of a robotic left hepatectomy using indocyanine green fluorescence imaging for a large biliary cyst.

Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst

Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Learn minimally invasive stone removal and primary duct closure using ICG fluorescence cholangiography and choledochoscopy. This technique avoids T-tube drainage and promotes faster patient recovery.

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

Explore More Videos