The Role of Indocyanine Green Fluorescence in Complex Laparoscopic Cholecystectomy Navigation

Summary

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

Abstract

Laparoscopic cholecystectomy (LC) is the gold-standard treatment for cholelithiasis and cholecystitis. In difficult cases with severe inflammation and adhesions, the risk of bile duct injury (BDI) is significantly higher. Precise identification of anatomical biliary structures is essential to prevent such injuries. Conventional intraoperative visualization techniques (IVT) have limited clinical application due to their complexity, increased trauma, and high error rates. Near-infrared fluorescence (NIRF) imaging, utilizing indocyanine green (ICG) as a fluorescent dye, has emerged as an innovative IVT technique. It is increasingly recognized as a feasible, safe, and effective approach for LC. However, the efficacy of NIRF in difficult LC procedures remains unclear, and the optimal timing and dosage of ICG administration are yet to be established. This article outlines the main steps for performing fluorescence-guided difficult LC in a patient with acute gangrenous cholecystitis and evaluates the imaging effects of NIRF in various scenarios. The patient was positioned supine, with four trocars placed. Upon switching to fluorescence mode, the fluorescently labeled bile ducts were readily identified. Following fluorescence guidance, Calot's triangle was carefully dissected. The cystic duct (CD) and cystic artery (CA) were individually identified and clipped before the gallbladder was extracted. Finally, the surgical field was inspected in fluorescence mode to detect bile leakage. With satisfactory ICG imaging and a smooth procedure, the patient's postoperative recovery was uneventful. NIRF is a safe and effective technology that shows great promise for future clinical applications.

Introduction

Approximately 20% of adults worldwide are affected by biliary stones, which can lead to acute cholecystitis -- a painful, rapidly progressing, and potentially life-threatening condition¹. Timely surgical intervention is imperative for patients with cholecystitis. Laparoscopic cholecystectomy (LC) has become widely accepted as the standard treatment for this condition.

However, conventional surgical approaches may present significant challenges in complex cases. Severe inflammation or adhesions can render biliary tracts indistinct, increasing the risk of inadvertent injury to bile ducts or arteries^2<....

Protocol

This research was conducted in compliance with the guidelines of the human research ethics committee of the Fifth Affiliated Hospital of Sun Yat-sen University. Written informed consent was obtained from the patient for participation in this study. The criteria for complex laparoscopic cholecystectomy (LC) included: gallbladder wall edema with thickening ≥4 mm; gangrenous cholecystitis with or without perforation; a history of upper abdominal surgery; impacted stones in the gallbladder neck; Mirizzi syndrome or variations in the extrahepatic bile duct; and cases requiring transcystic common bile duct exploration. Details of the reagents and equipment used are pr....

Results

Following the surgical procedure outlined in the protocol (Figure 2), fluorescence-guided laparoscopic cholecystectomy (LC) was successfully performed in three patients with difficult gallbladders. There were no conversions to open surgery and no occurrences of bile duct injury (BDI) during the procedure. No bile leakage was observed in fluorescence mode, as demonstrated in the accompanying video. The intraoperative and postoperative outcomes are summarized in Table 1.

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Discussion

Laparoscopic cholecystectomy (LC) has long been regarded as the gold standard treatment for cholelithiasis and cholecystitis. However, conventional surgical approaches often pose significant challenges in cases involving acute inflammation, gangrene, perforation, and anatomical variations-collectively referred to as difficult gallbladders¹⁶. These challenging conditions significantly increase the risks of bile duct injury (BDI) and cystic artery (CA) injury.

BDI is one .......

Materials

Name	Company	Catalog Number	Comments
3-0 MERSILK	JOHNSON MEDICAL (CHINA) LTD.	SA84G	The Suture Material
4-0 Coated VICRYL	ETHICON	VCP310	The Suture Material
Endoscopic Fluorescence Imaging System	ZHUHAI DI PU MEDICAL TECHNOLOGY CO., LTD.	H380022041YF	Fluorescence Laparoscope Equipment
Hem-O-lock Clips	SINOLINKS MEDICAL INNOVOATION, INC.	B240714	Hem-O-lock Clips
Indocyanine Green for Injection	DANDONG YICHUANG PHARMACEUTICAL CO., LTD.	H20055881	Fluorescence Dye