Routine use of fluorescent incisionless cholangiography as a new imaging modality during laparoscopic cholecystectomy. Surg Endosc. 2015;29:1621-1626. [PMID: 25277476 DOI: 10.1007/s00464-014-3853-7]

Role of indocyanine green-guided near-infrared fluorescence imaging in identification of the cause of neonatal cholestasis

To evaluate the efficacy and safety of indocyanine green (ICG)-guided near-infrared fluorescence (NIRF) imaging during surgery to diagnose the cause of neonatal cholestasis (NC). Data on NC patients who underwent both NIRF with ICG and conventional laparoscopic bile duct exploration (the gold standard) at our institute from January 2022 to December 2022 were retrospectively analyzed. The patients' baseline characteristics and liver function outcomes were collected and analyzed, and the diagnostic consistency was compared between the 2 methods. In total, 16 NC patients were included in the study, comprising 8 (50%) male and 8 (50%) female patients, ranging in age from 42 to 93 days, with a median age of 54.4 ± 21 days. During surgery, all the patients underwent NIRF with ICG, followed by conventional laparoscopic bile duct exploration. Finally, 15 of the patients were diagnosed with biliary atresia (BA) (1 with type-I BA, and 14 with type-II BA). The other patient was diagnosed with cholestasis. The diagnostic results from fluorescence imaging with ICG were consistent with those from conventional laparoscopic bile duct exploration. ICG-guided NIRF is associated with an easy operation, less trauma, and good safety. Also, its diagnostic accuracy is similar to conventional laparoscopic bile duct exploration.

Fluorescence and tracers in surgery: the coming future

The revolution that we are seeing in the world of surgery will determine the way we understand surgical approaches in coming years. Since the implementation of minimally invasive surgery, innovations have constantly been developed to allow the laparoscopic approach to go further and be applied to more and more procedures. In recent years, we have been in the middle of another revolutionary era, with robotic surgery, the application of artificial intelligence and image-guided surgery. The latter includes 3D reconstructions for surgical planning, virtual reality, holograms or tracer-guided surgery, where ICG-guided fluorescence has provided a different perspective on surgery. ICG has been used to identify anatomical structures, assess tissue perfusion, and identify tumors or tumor lymphatic drainage. But the most important thing is that this technology has come hand in hand with the potential to develop other types of tracers that will facilitate the identification of tumor cells and ureters, as well as different light beams to identify anatomical structures. These will lead to other types of systems to assess tissue perfusion without the use of tracers, such as hyperspectral imaging. Combined with the upcoming introduction of ICG quantification, these developments represent a real revolution in the surgical world. With the imminent implementation of these technological advances, a review of their clinical application in general surgery is timely, and this review serves that aim.

Indocyanine green fluorescent cholangiography: The new standard practice to perform laparoscopic cholecystectomy in pediatric patients. A comparative study with conventional laparoscopic technique

BACKGROUND

This study aimed to compare outcomes of standard laparoscopic cholecystectomy and indocyanine green fluorescent cholangiography laparoscopic cholecystectomy over a 10-year period.

METHODS

From 2013 to 2023, 173 laparoscopic cholecystectomies were performed in 2 pediatric surgery units: 83 using standard technique (G1) and 90 using indocyanine green fluorescent cholangiography (G2). Patients included 96 girls and 77 boys, with a median age of 12.3 years (range 4-17) and a median weight of 51 kg (range 19-114). The 2 groups were compared regarding the following: (1) perioperative complications rate; (2) overall length of surgery (T1); (3) length of cystic duct isolation, clipping, and sectioning (T2); (4) time of gallbladder removal (T3); (5) degree of visualization of biliary tree; (6) safety and feasibility of indocyanine green fluorescent cholangiography; (7) incidence of anatomical anomalies detected intraoperatively.

RESULTS

All laparoscopic cholecystectomies were accomplished without conversion to open. The perioperative complications rate was significantly higher in G1 compared with G2 (12% vs 0%; P = .0007). Median T1, T2, and T3 were significantly longer in G1 (90, 37, 35 minutes) compared with G2 (55, 17, 19 minutes) (P = .0001), respectively. The visualization rate of the complete biliary tree was significantly higher in G2 (98.8%) than in G1 (80.7%) (P = .0001). No adverse reactions to indocyanine green were recorded. The incidence of biliary anomalies detected intraoperatively was significantly higher in G2 (7.8%) than in G1 (1.2%) (P = .03).

CONCLUSION

Indocyanine green fluorescent cholangiography can be considered the new standard practice to perform laparoscopic cholecystectomy in pediatrics. Indocyanine green fluorescence provided superior visualization of biliary anatomy, increased detection of anatomic variants, faster procedure, and fewer complications compared with conventional technique. Indocyanine green fluorescent cholangiography was safe, feasible, simple, inexpensive, and a timesaving tool.

Fluorescence cholangiography for laparoscopic cholecystectomy: how, when, and why? A single-center preliminary study

INTRODUCTION

Bile duct injuries avoidance is a key goal of biliary surgery. In this prospective study we evaluate the safety and feasibility of ICG fluorescent cholangiography during laparoscopic cholecystectomy (LC) focusing on the optimization of timing and dose administration.

MATERIAL AND METHODS

From February to December 2022 fifty-four LC were performed with fluorescence imaging in our surgical department. 2.5 mg ICG were administered intravenously between 5 h and 24 h before surgery. Near-infrared fluorescent cholangiography (NIRF-C) was performed. Adequate fluorescence was evaluated by comparing agent accumulation in the gallbladder and the extrahepatic duct and the background of liver parenchyma.

RESULTS

Biliary anatomy was identified in all cases. Median time of ICG administration was 11 h previous surgery and three groups of patients were identified: group A receiving ICG 5-9 h, group B 10-14 h, group C 15-24 h before surgery. Peak contrast was gained in group B, with minimal fluorescence of liver parenchyma and more intense visibility of the biliary tract. Intraoperative cholangiogram was unnecessary in all cases.

CONCLUSION

Fluorescent cholangiography during LC is safe and feasible overcoming the limits of other techniques available. 2.5 mg ICG administered 10-14 h before surgery produces optimal outcomes for near-infrared (NIR) fluorescent cholangiography.

Identification of the ideal weight-based indocyanine green dose for fluorescent cholangiography

BACKGROUND

Ideal visualization of fluorescent cholangiography during laparoscopic cholecystectomy is when maximum fluorescence into biliary ducts and absent signal into liver parenchyma, defined as "signal to background ratio" (SBR), is obtained. Such condition is mainly dependent by indocyanine green (ICG) dose and timing. The aim of this study was to identify the ideal ICG dose to obtain the best possible intraoperative visualization of the extra-hepatic biliary tree.

METHODS

The first part of the study was used to define a range of small weight-based ICG dosages using the mathematical function bisection method. During the second part of the study, the midpoint dose of the identified range, was tested in 50 consecutive cholecystectomies using a laser-based fluorescence laparoscopic camera (SynergyID system by Arthrex, Naples, FL, USA). Timing administration was set at 1 h before surgery, since this is the most common situation in clinical practice. Fluorescence intensity of bile ducts and liver parenchyma were assessed both subjectively, by blinded operative surgeon, as well as objectively, using an image analysis software (Fiji plugin), before and after Calot's triangle dissection.

RESULTS

Fourteen patients were included in the first part of the study and ICG dose between 0.01191406 and 0.0119873 mg/kg was identified. The second part confirmed previous results after testing the dosage equal to 0.0119 mg/kg (midpoint of the defined range) in 50 consecutive cholecystectomies. Cystic duct was identified in 66 and 100% of cases before and after dissection of Calot's triangle respectively. On the other hand, common bile duct was identified in 82 and 92% before and after dissection respectively. Subjective and objective SBRs confirmed the benefit of the identified ICG dose.

CONCLUSION

ICG dose calculated by 0.0119 mg/kg administered one hour before surgery allows an ideal intraoperative visualization of the extra-hepatic biliary tree.

REGISTRATION NUMBER

ISRCTN10190039.

Is the use of a routine intraoperative cholangiogram necessary in laparoscopic cholecystectomy?

INTRODUCTION

Although laparoscopic cholecystectomy (LC) has been standard of care for symptomatic gallstone disease for almost 30 years, the use of routine intraoperative cholangiogram (IOC) remains controversial. There are marked variations in the use IOC during LC internationally. Debate has continued about its benefit, in part because of inconsistent benefit, time, and resources required to complete IOC. This literature review is presented as a debate to outline the arguments in favour of and against routine IOC in laparoscopic cholecystectomy.

METHODS

A standard literature review of PubMed, Medline, OVID, EMBASE, CINHIL and Web of Science was performed, specifically for literature pertaining to the use of IOC or alternative intra-operative methods for imaging the biliary tree in LC. Two authors assembled the evidence in favour, and two authors assembled the evidence against.

RESULTS

From this controversies piece we found that there is little discernible change in the number of BDIs requiring repair procedures. Although IOC is associated with a small absolute reduction in bile duct injury, there are other confounding factors, including a change in laparoscopic learning curves. Alternative technologies such as intra-operative ultrasound, indocyanine green imaging, and increased access to ERCP may contribute to a reduction in the need for routine IOC.

CONCLUSIONS

In spite of 30 years of accumulating evidence, routine IOC remains controversial. As technology advances, it is likely that alternative methods of imaging and accessing the bile duct will supplant routine IOC.

Use of Near-Infrared Fluorescence Techniques in Minimally Invasive Surgery for Colorectal Liver Metastases

Colorectal liver metastases (CRLM) afflict a significant proportion of patients with colorectal cancer (CRC), ranging from 25% to 30% of patients throughout the course of the disease. In recent years, there has been a surge of interest in the application of near-infrared fluorescence (NIRF) imaging as an intraoperative imaging technique for liver surgery. The utilisation of NIRF-guided liver surgery, facilitated by the administration of fluorescent dye indocyanine green (ICG), has gained traction in numerous medical institutions worldwide. This innovative approach aims to enhance lesion differentiation and provide valuable guidance for surgical margins. The use of ICG, particularly in minimally invasive surgery, has the potential to improve lesion detection rates, increase the likelihood of achieving R0 resection, and enable anatomically guided resections. However, it is important to acknowledge the limitations of ICG, such as its low specificity. Consequently, there has been a growing demand for the development of tumour-specific fluorescent probes and the advancement of camera systems, which are expected to address these concerns and further refine the accuracy and reliability of intraoperative fluorescence imaging in liver surgery. While NIRF imaging has been extensively studied in patients with CRLM, it is worth noting that a significant proportion of published research has predominantly focused on the detection of hepatocellular carcinoma (HCC). In this study, we present a comprehensive literature review of the existing literature pertaining to intraoperative fluorescence imaging in minimally invasive surgery for CRLM. Moreover, our analysis places specific emphasis on the techniques employed in liver resection using ICG, with a focus on tumour detection in minimal invasive surgery (MIS). Additionally, we delve into recent developments in this field and offer insights into future perspectives for further advancements.

Low vs Standard-Dose Indocyanine Green in the Identification of Biliary Anatomy Using Near-Infrared Fluorescence Imaging: A Multicenter Randomized Controlled Trial

BACKGROUND

Near-infrared fluorescence imaging using intravenous indocyanine green (ICG) facilitates intraoperative identification of biliary anatomy. We hypothesize that a much lower dose of ICG than the standard decreases hepatic and background fluorescence and improves bile duct visualization.

STUDY DESIGN

In this multicenter randomized controlled trial, 55 adult patients undergoing laparoscopic cholecystectomy were randomized to low-dose (0.05 mg) or standard-dose (2.5 mg) ICG preoperatively on the day of surgery. A quantitative assessment was performed on recorded videos from the operation using ImageJ software to quantify the fluorescence intensity of the bile duct, liver, and surrounding/background fat. Operating surgeons blinded to ICG dose provided a qualitative assessment of various aspects of the visualization of the extrahepatic biliary tree comparing near-infrared fluorescence to standard visible light imaging using a scale of 1 to 5 (1, unsatisfactory; 5, excellent). Quantitative and qualitative scores were compared between the groups to determine any significant differences between the doses.

RESULTS

The bile duct-to-liver and bile duct-to-background fat fluorescence intensity ratios were significantly higher for the low-dose group compared with the standard-dose group (3.6 vs 0.68, p < 0.0001; and 7.5 vs 3.3, p < 0.0001, respectively). Low-dose ICG had a slightly higher (ie better) mean score on the qualitative assessment compared to the standard dose, although the differences were not statistically significant.

CONCLUSIONS

Low-dose ICG leads to quantitative improvement of biliary visualization using near-infrared fluorescence imaging by minimizing liver fluorescence; this further facilitates routine use during hepatobiliary operations.

Opportunities of ICG-fluorescent imaging of lymph nodes during radical cystectomy in patients with bladder cancer: A review

Today, the "golden standard" for the treatment of aggressive forms of bladder cancer is radical cystectomy. An important stage is the pelvic lymphadenectomy. This procedure is crucial for staging the tumor process, determining the subsequent treatment tactics and improving the results of surgery. Currently, the concept of a signaling lymph node (LN) is actively developing, which allows reducing the necessary level of dissection of the pelvic LN. Reducing the number of resected LN increases the level of surgical safety of the patient. The leading method of intraoperative visualization of signal LN is the fluorescence of indocyanine green in the near infrared range of the spectrum. The prospects of this diagnostic method for radical cystectomy in patients with bladder cancer determine the vector of future scientific research in this area.

Indocyanine green (ICG) fluorescence guide for the use and indications in general surgery: recommendations based on the descriptive review of the literature and the analysis of experience

Indocyanine Green is a fluorescent substance visible in near-infrared light. It is useful for the identification of anatomical structures (biliary tract, ureters, parathyroid, thoracic duct), the tissues vascularization (anastomosis in colorectal, esophageal, gastric, bariatric surgery, for plasties and flaps in abdominal wall surgery, liver resection, in strangulated hernias and in intestinal ischemia), for tumor identification (liver, pancreas, adrenal glands, implants of peritoneal carcinomatosis, retroperitoneal tumors and lymphomas) and sentinel node identification and lymphatic mapping in malignant tumors (stomach, breast, colon, rectum, esophagus and skin cancer). The evidence is very encouraging, although standardization of its use and randomized studies with higher number of patients are required to obtain definitive conclusions on its use in general surgery. The aim of this literature review is to provide a guide for the use of ICG fluorescence in general surgery procedures.

Near-infrared fluorescence cholangiography at a very low dose of indocyanine green: quantification of fluorescence intensity using a colour analysis software based on the RGB color model

BACKGROUND

Indocyanine green (ICG) near-infrared fluorescence cholangiography (NIRF-C) is widely used to visualize the biliary tract during laparoscopic cholecystectomy (LC). However, the ICG dose and its dosing time vary in the literature so there is not a standard ICG protocol. The objectives of this descriptive prospective study were to demonstrate that NIRF-C at a very low dose of ICG provides good visualization of the extrahepatic biliary tree while avoiding hepatic hyperluminescence and to assess the surgeon-perceived benefit. Furthermore, another additional aim was quantifying the amount of ICG dye in the liver tissue and biliary tract through a green colour intensity (GCI) analysis according to red green blue (RGB) color model and correlating it to surgeon-perceived benefit.

METHOD

Forty-four patients were scheduled for LC. We recorded demographics, surgical indication, intraoperative details, adverse reactions to ICG, hepatic hyperluminescence, visualization of the cystic duct (CD), the common bile duct (CBD) and the cystic duct-bile duct junction (CDBDJ) before and after dissection of Calot's triangle, operation time, surgical complications and subjective surgeon data. For all procedures, a unique dose of 0.25 mg of ICG was administered intravenously during the anaesthetic induction. ICG NIRF-C was performed using the overlay mode of the VISERA ELITE II Surgical Endoscope in all surgeries. Video recordings of all 44 LC were reviewed. Using a color analysis software, the GCI of CBD versus adjacent liver tissue was calculated using RGB color model.

RESULTS

ICG NIRF-C was performed in all 44 cases. The mean operation time was 45 ± 15 min. There were no bile duct injuries (BDIs) or allergic reactions to ICG. The postoperative course was uneventful in all of cases. The mean postoperative hospital stay was 28 ± 4 h. ICG NIRF-C identified the CBD in 100% of the patients, the CD in 71% and the CDBDJ in 84%, with a surgeon satisfaction of 4/5 or 5/5 in almost 90% of surgeries based on a visual analogue scale (VAS). No statistically significant differences were found in the visualization of the biliary structures after the dissection of Calot's triangle in obese patients or with gallbladder inflammation. Furthermore, 25% of patients with a BMI ≥ 30, 27% of patients with a Nassar grade ≥ 3 and 21% of patients with gallbladder inflammation had a VAS score 5/5 compared to 6% of patients with a BMI < 30 (p = 0.215), 6% of patients with a Nassar grade < 3 (p = 0.083) and none of the patients without gallbladder inflammation (p = 0.037). Measured pixel GCI of CBD was higher than adjacent hepatic tissue for all cases regardless of the degree of gallbladder inflammation, the Nassar scale grades or the patient's BMI (p < 0.0001). In addition, a significant correlation was observed between surgeon-perceived benefit and the amount of ICG dye into the CBD according the RGB color model (p < 0.0001).

CONCLUSION

ICG NIRF-C at a very low dose of ICG (0.25 mg of ICG 20 min before surgery) enables the real-time identification of biliary ducts, thereby avoiding the hepatic hyperluminescence even in cases of obese patients or those with gallbladder inflammation.

Near infrared indocyanine green fluorescent cholangiography versus intraoperative cholangiography to improve safety in laparoscopic cholecystectomy for gallstone disease-a systematic review protocol

BACKGROUND

Laparoscopic cholecystectomy has become the standard surgical approach in the treatment of cholelithiasis. Diverse surgical techniques and different imaging modalities have been described to evaluate the biliary anatomy and prevent or early detect bile duct injuries. X-ray intraoperative cholangiography (IOC) and near infrared indocyanine green fluorescent cholangiography (NIR-ICG) are safe and feasible techniques to assess biliary anatomy. The aim of this systematic review will be to evaluate if NIR-ICG can visualize extrahepatic biliary anatomy more efficiently and safer than IOC in minimally invasive cholecystectomy for gallstone disease.

METHODS

Literature search will be performed via MEDLINE (PubMed), Embase, Scopus, the Cochrane Central Register of Controlled Trials, and Web of Science Core Collection from 2009 to present. All randomized controlled clinical trials and prospective non-randomized controlled trials which report on comparison of NIR-ICG versus IOC will be included. All patients over 18 years old who require elective or urgent minimally invasive cholecystectomy (undergoing NIR-ICG during this procedure) due to gallstone disease both acute and chronic will be included. Since BDI has a low incidence, the primary outcome will be the ability to visualize extrahepatic biliary anatomy and the time to obtain relevant images of these structures. Two researchers will individually screen the identified records, according to a list of inclusion and exclusion criteria. Bias of the studies will be evaluated with the Newcastle-Ottawa score for non-randomized studies and with The Cochrane Risk of Bias Tool for randomized controlled trials. Quality of evidence for all outcomes will be determined with the GRADE system. The data will be registered in a predesigned database. If selected studies are sufficiently homogeneous, we will perform a meta-analysis of reported results. In the event of a substantial heterogeneity, a narrative synthesis will be provided. Subgroup analysis will be used to investigate possible sources of heterogeneity.

DISCUSSION

Understanding the benefits of this technique is critical to ensuring policymakers can make informed decisions as to where preventive efforts should be focused regarding specific imaging techniques. If ICG is proven to be faster and non-invasive, its routine use could be encouraged.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020177991 .

The price is right: Routine fluorescent cholangiography during laparoscopic cholecystectomy

BACKGROUND

Early experience with indocyanine green-based fluorescent cholangiography during laparoscopic cholecystectomy suggests the potential to improve outcomes. However, the cost-effectiveness of routine use has not been studied. Our objective was to evaluate the cost-effectiveness of fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy for noncancerous gallbladder disease.

METHODS

A Markov model decision analysis was performed comparing fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy alone. Probabilities of outcomes, survival, toxicities, quality-adjusted life-years, and associated costs were determined from literature review and pooled analysis of currently available studies on fluorescent cholangiography (n = 37). Uncertainty in the model parameters was evaluated with 1-way and probabilistic sensitivity analyses, varying parameters up to 40% of their means. Cost-effectiveness was measured with an incremental cost-effectiveness ratio expressed as the dollar amount per quality-adjusted life-year.

RESULTS

The model predicted that fluorescent cholangiography reduces lifetime costs by $1,235 per patient and improves effectiveness by 0.09 quality-adjusted life-years compared to standard bright light laparoscopic cholecystectomy. Reduced costs were due to a decreased operative duration (21.20 minutes, P < .0001) and rate of conversion to open (1.62% vs 6.70%, P < .0001) associated with fluorescent cholangiography. The model was not influenced by the rate of bile duct injury. Probabilistic sensitivity analysis found that fluorescent cholangiography was both more effective and less costly in 98.83% of model iterations at a willingness-to-pay threshold of $100,000/quality-adjusted life year.

CONCLUSION

The current evidence favors routine use of fluorescent cholangiography during laparoscopic cholecystectomy as a cost-effective surgical strategy. Our model predicts that fluorescent cholangiography reduces costs while improving health outcomes, suggesting fluorescence imaging may be considered standard surgical management for noncancerous gallbladder disease. Further study with prospective trials should be considered to verify findings of this predictive model.

Laparoscopic cholecystectomy completely guided by indocyanine green fluorescence in a patient with gallstone: A case report

Introduction

We report the execution of a cholecystectomy under complete fluorescence guidance using near-infrared camera images without switching to the white light mode, a method that has not been reported previously.

Presentation of case

An Asian woman in her fifties with no history of abdominal surgery was administered indocyanine green (ICG, 25 mg) intravenously 16 h before the surgery. Laparoscopic surgery was performed using VISION SENSE® with the four-trocar technique. The entire laparoscopic procedure was performed under fluorescence guidance. The orientation of the gallbladder neck can be recognized from the beginning of the procedure, and the serosal first incision could be positioned appropriately. All procedures were performed while the common bile duct was visualized. Peeling around the cystic duct and gallbladder bed was appropriately guided by ICG fluorescence.

Discussion

This method may be a safer form of surgery because the fluorescence did not disturb the surgical procedures.

Conclusion

Since this method was successful in this case, a case series is warranted.

•

A cholecystectomy under complete fluorescence guidance (C-CFG) was performed.

•

C-CFG was performed without switching to the white light mode.

•

All procedures can be performed while visualizing the common bile duct.

•

Peeling around the cystic duct was appropriately guided by ICG fluorescence.

•

The line to be peeled is clearly recognized while being exfoliated from the liver.

Efficacy of indocyanine green (ICG) fluorescent cholangiography to improve intra-operative visualization during laparoscopic cholecystectomy in pediatric patients: a comparative study between ICG-guided fluorescence and standard technique

BACKGROUND

In the last few years, indocyanine green (ICG) fluorescent cholangiography (FC) has been adopted to perform intra-operative biliary mapping during laparoscopic cholecystectomy (LC). This study aimed to compare the results of LC with and without use of ICG-FC.

METHODS

All LC operated from June 2017 to June 2021 in our unit were retrospectively reviewed. Pre-operative workup included ultrasonography to assess dilation of main biliary tree. The ICG dosage was 0.35 mg/kg and the median timing of administration was 15.5 h pre-operatively. We evaluated, analyzing videorecorded procedures, 3 parameters in both groups: the total operative time (T1), the time of cystic duct isolation, clipping and sectioning (T2), and the time of gallbladder removal from hepatic fossa (T3).

RESULTS

Forty-three LC were operated in the study period: 22 using standard technique (G1) and 21 using ICG-FC (G2). There were 27 girls and 16 boys, with median age at surgery of 11.5 years (range 7-17) and median weight of 47 kg (range 31-110). No conversions were reported in our series. In all ICG cases (except one patient under therapy with phenobarbital) the biliary tree was perfectly visualized during dissection. Intra-operative complications occurred in 3 G1 patients (13.6%): 2 bleedings from the Calot's triangle and 1 bleeding from the liver bed during the gallbladder removal. LC was significantly faster in G2 than in G1 (p = 0.001). In fact, the parameters analyzed (T1, T2, T3) were all significantly greater in G1 than in G2 (p = 0.001).

CONCLUSIONS

Based upon our experience, we strongly recommend the use of ICG-FC in all pediatric patients undergoing LC. ICG-guided fluorescence provided an excellent real-time visualization of the extrahepatic biliary tree and allowed faster and safer dissection, minimizing the risk of bile duct injuries. Furthermore, ICG use was clinically safe, with no adverse reactions to the product.

Direct gallbladder indocyanine green injection technique to achieve critical view of safety in laparoscopic cholecystectomy

INTRODUCTION

Bile duct injury is one of the most severe complications after cholecystectomy. The aim of this study is to demonstrate how with a simple technique, an optimal critical view may be achieved by injecting indocyanine green directly into the gallbladder.

METHODS

Twenty-three patients were prospectively studied in which direct gallbladder injection of indocyanine green during laparoscopy was administered with a fine needle using an easily reproducible technique.

RESULTS

Biliary tree identification was reported before and after injection. Critical view of safety was achieved in all cases.

CONCLUSIONS

Our technique of direct gallbladder injection of indocyanine green is simple, efficient and shows a real time fluorescent cholangiography and an optimal critical view of safety decreasing the risk for bile duct injury.

Fluorescent cholangiography: An up-to-date overview twelve years after the first clinical application

Laparoscopic cholecystectomy (LC) is one of the most frequently performed gastrointestinal surgeries worldwide. Bile duct injury (BDI) represents the most serious complication of LC, with an incidence of 0.3%-0.7%, resulting in significant perioperative morbidity and mortality, impaired quality of life, and high rates of subsequent medico-legal litigation. In most cases, the primary cause of BDI is the misinterpretation of biliary anatomy, leading to unexpected biliary lesions. Near-infrared fluorescent cholangiography is widely spreading in clinical practice to delineate biliary anatomy during LC in elective and emergency settings. The primary aim of this article was to perform an up-to-date overview of the evolution of this method 12 years after the first clinical application in 2009 and to highlight all advantages and current limitations according to the available scientific evidence.

Indocyanine green (ICG) fluorescent cholangiography during laparoscopic cholecystectomy using RUBINA™ technology: preliminary experience in two pediatric surgery centers

Background

Recently, we reported the feasibility of indocyanine green (ICG) near-infrared fluorescence (NIRF) imaging to identify extrahepatic biliary anatomy during laparoscopic cholecystectomy (LC) in pediatric patients. This paper aimed to describe the use of a new technology, RUBINA™, to perform intra-operative ICG fluorescent cholangiography (FC) in pediatric LC.

Methods

During the last year, ICG-FC was performed during LC using the new technology RUBINA™ in two pediatric surgery units. The ICG dosage was 0.35 mg/Kg and the median timing of administration was 15.6 h prior to surgery. Patient baseline, intra-operative details, rate of biliary anatomy identification, utilization ease, and surgical outcomes were assessed.

Results

Thirteen patients (11 girls), with median age at surgery of 12.9 years, underwent LC using the new RUBINA™ technology. Six patients (46.1%) had associated comorbidities and five (38.5%) were practicing drug therapy. Pre-operative workup included ultrasound (n = 13) and cholangio-MRI (n = 5), excluding biliary and/or vascular anatomical anomalies. One patient needed conversion to open surgery and was excluded from the study. The median operative time was 96.9 min (range 55–180). Technical failure of intra-operative ICG-NIRF visualization occurred in 2/12 patients (16.7%). In the other cases, ICG-NIRF allowed to identify biliary/vascular anatomic anomalies in 4/12 (33.3%), including Moynihan's hump of the right hepatic artery (n = 1), supravescicular bile duct (n = 1), and short cystic duct (n = 2). No allergic or adverse reactions to ICG, post-operative complications, or reoperations were reported.

Conclusion

Our preliminary experience suggested that the new RUBINA™ technology was very effective to perform ICG-FC during LC in pediatric patients. The advantages of this technology include the possibility to overlay the ICG-NIRF data onto the standard white light image and provide surgeons a constant fluorescence imaging of the target anatomy to assess position of critical biliary structures or presence of anatomical anomalies and safely perform the operation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08596-7.

Consensus Guidelines for the Use of Fluorescence Imaging in Hepatobiliary Surgery

OBJECTIVE

To establish consensus recommendations for the use of fluorescence imaging with indocyanine green (ICG) in hepatobiliary surgery.

BACKGROUND

ICG fluorescence imaging has gained popularity in hepatobiliary surgery in recent years. However, there is varied evidence on the use, dosage, and timing of administration of ICG in clinical practice. To standardize the use of this imaging modality in hepatobiliary surgery, a panel of pioneering experts from the Asia-Pacific region sought to establish a set of consensus recommendations by consolidating the available evidence and clinical experiences.

METHODS

A total of 13 surgeons experienced in hepatobiliary surgery and/or minimally invasive surgery formed an expert consensus panel in Shanghai, China in October 2018. By the modified Delphi method, they presented the relevant evidence, discussed clinical experiences, and derived consensus statements on the use of ICG in hepatobiliary surgery. Each statement was discussed and modified until a unanimous consensus was achieved.

RESULTS

A total of 7 recommendations for the clinical applications of ICG in hepatobiliary surgery were formulated.

CONCLUSIONS

The Shanghai consensus recommendations offer practical tips and techniques to augment the safety and technical feasibility of ICG fluorescence-guided hepatobiliary surgery, including laparoscopic cholecystectomy, liver segmentectomy, and liver transplantation.

Preliminary application of indocyanine green fluorescence imaging in postoperative gastrointestinal fistula

We describe a case using indocyanine green (ICG) fluorescence imaging for diagnosis of postoperative gastrointestinal fistula. When the fistula is very large, both indocyanine green and methylene blue can be found in the postoperative drainage. After treatment, when the leak became small, only ICG fluorescence imaging continued to be demonstrated. ICG fluorescence imaging is likely to prove to be a safe and effective method of examination, and one that is very practical and easy to execute for the diagnosis of postoperative gastrointestinal fistula.

The Efficacy of Intraoperative Fluorescent Imaging Using Indocyanine Green for Cholangiography During Cholecystectomy and Hepatectomy

Purpose

Bile duct injury is one of the most serious complications of laparoscopic cholecystectomy. Intraoperative indocyanine green (ICG) cholangiography is a safe and useful navigation modality for confirming the biliary anatomy. ICG cholangiography is expected to be a routine method for helping avoid bile duct injuries.

Patients and Methods

We examined 25 patients who underwent intraoperative cholangiography using ICG fluorescence. Two methods of ICG injection are used: intrabiliary injection (percutaneous transhepatic gallbladder drainage [PTGBD], gallbladder [GB] puncture and endoscopic nasobiliary drainage [ENBD]) at a dosage of 0.025 mg during the operation or intravenous injection with 2.5 mg ICG preoperatively.

Results

There were 24 patients who underwent laparoscopic cholecystectomy and 1 patient who underwent hepatectomy. For laparoscopic cholecystectomy, the average operation time was 127 (50–197) minutes, and estimated blood loss was 43.2 (0–400) g. The ICG administration route was intravenous injections in 12 cases and intrabiliary injection in 12 cases (GB injection: 3 cases, PTGBD: 8 cases, ENBD:1 case). The course of the biliary tree was able to be confirmed in all cases that received direct injection into the biliary tract, whereas bile structures were recognizable in only 10 cases (83.3%) with intravenous injection. The postoperative hospital stay was 4.6 (3–9) days, and no postoperative complications (Clavien–Dindo ≧IIIa) were observed. For hepatectomy, a tumor located near the left Glissonian pedicle was resected using a fluorescence image guide. Biliary structures were fluorescent without injury after resecting the tumor. No adverse events due to ICG administration were observed, and the procedure was able to be performed safely.

Conclusion

ICG fluorescence imaging allows surgeons to visualize the course of the biliary tree in real time during cholecystectomy and hepatectomy. This is considered essential for hepatobiliary surgery to prevent biliary tree injury and ensure safe surgery.

Comparison of indocyanine green dye fluorescent cholangiography with intra-operative cholangiography in laparoscopic cholecystectomy: a meta-analysis

OBJECTIVE

To compare indocyanine green dye fluorescence cholangiography (ICG-FC) with intra-operative cholangiography (IOC) in minimal access cholecystectomy for visualization of the extrahepatic biliary tree.

BACKGROUND

Although studies have shown that ICG-FC is safe, feasible, and comparable to IOC to visualize the extrahepatic biliary tree, there is no comparative review.

METHODS

We searched The Embase, PubMed, Cochrane Library, and Web of Science databases up to 8 April 2020 for all studies comparing ICG-FC with IOC in patients undergoing minimal access cholecystectomy. The primary outcomes were percentage visualization of the cystic duct (CD), common bile duct (CBD), CD-CBD junction, and the common hepatic duct (CHD). We used RevMan v5.3 software to analyze the data.

RESULTS

Seven studies including 481 patients were included. Five studies, comprising 275 patients reported higher CD (RR = 0.90, p = 0.12, 95% CI 0.79-1.03, I² = 74%) and CBD visualization rates (RR = 0.82, p = 0.09, 95% CI 0.65-1.03, I² = 87%) by ICG-FC. Four studies, comprising 223 patients, reported higher CD-CBD junction visualization rates using ICG-FC compared to IOC (RR = 0.68, p = 0.06, 95% CI = 0.45-1.02, I² = 94%). Four studies, comprising 210 patients, reported higher CHD visualization rates using ICG-FC compared to IOC (RR = 0.58, p = 0.03, 95% CI 0.35-0.93, I² = 91%).

CONCLUSION

ICG-FC is safe, and it improves visualization of CHD.

Direct gallbladder Indocyanine Green injection technique to achieve critical view of safety in laparoscopic cholecystectomy

INTRODUCTION

Bile duct injury is one of the most severe complications after cholecystectomy. The aim of this study is to demonstrate how with a simple technique, an optimal critical view may be achieved by injecting indocyanine green directly into the gallbladder.

METHODS

Twenty-three patients were prospectively studied in which direct gallbladder injection of indocyanine green during laparoscopy was administered with a fine needle using an easily reproducible technique.

RESULTS

Biliary tree identification was reported before and after injection. Critical view of safety was achieved in all cases.

CONCLUSIONS

Our technique of direct gallbladder injection of indocyanine green is simple, efficient and shows a real time fluorescent cholangiography and an optimal critical view of safety decreasing the risk for bile duct injury.

A visual quantification of tissue distinction in robotic transabdominal lateral adrenalectomy: comparison of indocyanine green and conventional views

BACKGROUND

Recent studies have reported the feasibility of indocyanine green fluorescence imaging of adrenal tumors to guide dissection. Although the adrenal has been reported to concentrate the dye more than surrounding tissues, the amount of tissue distinction and how this compares with conventional vision has not been quantified before. The aim of this study is to quantify this distinction using color analysis.

METHODS

This was an institutional review board-approved retrospective study. By excluding adrenal cortical carcinoma, metastasis and pheochromocytoma, video recordings of 50 patients who underwent robotic transabdominal lateral adrenalectomy with indocyanine green (ICG) imaging for adrenocortical tumors between August 2015 and May 2018 were reviewed. Using a color analysis software, the pixel intensity of adrenal tumors versus adjacent retroperitoneal tissues was calculated for conventional red, green and blue, as well as indocyanine green (ICG) scales. Statistical analysis was performed using ANOVA.

RESULTS

A total of 50 patients underwent unilateral robotic transabdominal lateral adrenalectomy. All procedures were completed robotically without a conversion to laparoscopy or open. Morbidity was 4%. Measured pixel intensity of adrenal tumors was higher than adjacent retroperitoneal tissues for all conventional color and ICG modes (p < 0.0001), with the gradient being more pronounced for ICG green versus conventional red, green and blue modes.

CONCLUSIONS

To our knowledge this is the first study attempting to encode tissue planes in robotic adrenalectomy. The results show that the visual contrast distinction observed between adrenal and adjacent retroperitoneal tissues can be quantified using pixel intensity. ICG enabled the distinction of tissue planes with a wider gradient compared to conventional RGB view, quantifying its subjective benefits reported in prior studies.

Understanding intraoperative fluorescent cholangiography: ten steps for an effective and successful procedure

BACKGROUND

Common bile duct injuries (BDI) during laparoscopic cholecystectomy (LC) continue to be the source of morbidity and mortality. The reason for BDI is mostly related to the misidentification of the extrahepatic bile duct structures and the anatomic variability. Near-infrared fluorescent cholangiography (NIFC) has proven to enhance visualization of extrahepatic biliary structures during LCs. The purpose of this study was to describe the most important steps in the performance of NIFC.

METHODS

In accordance to the most current surgical practice of LC at our institution, a consensus was achieved on the most relevant steps to be followed when utilizing NIFC. Dose of indocyanine green (ICG), time of administration, and identification of critical structures were previously determined based on prospective and randomized controlled studies performed at CCF.

RESULTS

The ten steps identified as critical when performing NIFC during LC are preoperative administration of ICG, exposure of the hepatoduodenal ligament, initial anatomical evaluation, identification of the cystic duct and common bile duct junction, the cystic duct and its junction to the gallbladder, the CHD, the common bile duct, accessory ducts, cystic artery and, time-out and identification of Calot's triangle, and evaluation of the liver bed.

CONCLUSIONS

Routine use of NIFC is a useful diagnostic tool to better visualize the extrahepatic biliary structures during LC. The implementation of specific standardized steps might provide the surgeon with a better algorithm to use this technology and consequently reduce the incidence of BDI.

Does near-infrared fluorescent cholangiography with indocyanine green reduce bile duct injuries and conversions to open surgery during laparoscopic or robotic cholecystectomy? - A meta-analysis

BACKGROUND

Bile duct injury and conversion-to-open-surgery rates remain unacceptably high during laparoscopic and robotic cholecystectomy. In a recently published randomized clinical trial, using near-infrared fluorescent cholangiography with indocyanine green intraoperatively markedly enhanced biliary-structure visualization. Our systematic literature review compares bile duct injury and conversion-to-open-surgery rates in patients undergoing laparoscopic or robotic cholecystectomy with versus without near-infrared fluorescent cholangiography.

METHODS

A thorough PubMed search was conducted to identify randomized clinical trials and nonrandomized clinical trials with ≥100 patients. Because all near-infrared fluorescent cholangiography studies were published since 2013, only studies without near-infrared fluorescent cholangiography published since 2013 were included for comparison. Incidence estimates, weighted and unweighted for study size, were adjusted for acute versus chronic cholecystitis, and for robotic versus laparoscopic cholecystectomy and are reported as events/10,000 patients. All studies were assessed for bias risk and high-risk studies excluded.

RESULTS

In total, 4,990 abstracts were reviewed, identifying 5 near-infrared fluorescent cholangiography studies (3 laparoscopic cholecystectomy/2 robotic cholecystectomy; n = 1,603) and 11 not near-infrared fluorescent cholangiography studies (5 laparoscopic cholecystectomy/4 robotic cholecystectomy/2 both; n = 5,070) for analysis. Overall weighted rates for bile duct injury and conversion were 6 and 16/10,000 in near-infrared fluorescent cholangiography patients versus 25 and 271/10,000 in patients without near-infrared fluorescent cholangiography. Among patients undergoing laparoscopic cholecystectomy, bile duct injuries, and conversion rates among near-infrared fluorescent cholangiography versus patients without near-infrared fluorescent cholangiography were 0 and 23/10,000 versus 32 and 255/10,000, respectively. Bile duct injury rates were low with robotic cholecystectomy with and without near-infrared fluorescent cholangiography (12 and 8/10,000), but there was a marked reduction in conversions with near-infrared fluorescent cholangiography (12 vs 322/10,000).

CONCLUSION

Although large comparative trials remain necessary, preliminary analysis suggests that using near-infrared fluorescent cholangiography with indocyanine green intraoperatively sizably decreases bile duct injury and conversion-to-open-surgery rates relative to cholecystectomy under white light alone.

Extrahepatic biliary tract visualization using near-infrared fluorescence imaging with indocyanine green: optimization of dose and dosing time

BACKGROUND

The dose and dosing time of indocyanine green (ICG) vary among fluorescence cholangiography (FC) studies. The purpose of this prospective, randomized, exploratory clinical trial was to optimize the dose and dosing time of ICG.

METHODS

PubMed was searched to determine the optimal dose. To optimize the dosing time of ICG, a clinical trial was designed with two parts. The first part included patients with T tubes for more than 1 month. After the patient was injected with ICG, bile was collected at 10 time points to explore the change and trends of bile fluorescence intensity (FI). In addition, the results of the first experiment were used to setup a randomized controlled trial (RCT) that aimed to find the optimal dosing timing for ICG injections for laparoscopic cholecystectomy (LC). During surgery, imaging data were collected for analysis.

RESULTS

After performing a systematic review, the ICG injection dose for each patient in the clinical trial was 10 mg. Five patients were included in the first part of the study. Bile collected 8 h after ICG injection had a higher FI than bile collected at other time points (p < 0.05), and the FI of bile collected 20 h after ICG injection was nearly zero. In the second part of the experiment, 4 groups of patients (6 patients per group) were injected with 10 mg ICG at 8, 10, 12 and 14 h prior to surgery. The distribution of bile duct FI (p = 0.001), liver FI (p < 0.001), and common bile duct (CBD)-to-liver contrast (p = 0.001) were not the same in each group. Further analysis with the Bonferroni method revealed the following: (1) the FI of the CBD in the 8 h group was significantly different from that in the 14 h group (adjusted p < 0.001); (2) the liver FI of the 8 h group was higher than that of the 10 h group (adjusted p = 0.042) and the 14 h group (adjusted p < 0.001); and (3) the CBD-to-liver contrast of the 8 h group was lower than that of the 10 h group (adjusted p = 0.013) and the 14 h group (adjusted p = 0.001).

CONCLUSION

ICG FC enables the real-time identification of extrahepatic bile ducts. The optimal effect of FC can be achieved by performing 10 mg ICG injections 10 to 12 h prior to surgery.

Fluorescence-guided hepatobiliary surgery with long and short wavelength fluorophores

Importance

Fluorescence-guided surgery (FGS) is a potentially powerful tool for hepatobiliary (HPB) surgery. The high sensitivity of fluorescence navigation is especially useful in settings where tactile feedback is limited.

Objective

The present narrative review evaluates literature on the use of FDA-approved fluorophores such as methylene blue (MB), 5-aminolevulinic acid (5-ALA), and indocyanine green (ICG) for clinical intra-operative image-guidance during HPB surgery.

Evidence Review

Approaches such as dosing, timing, imaging devices and comparative endpoints are summarized. The feasibility and safety of fluorophores in visualizing the biliary tree, identify biliary leaks, outline anatomic hepatic segments, identify tumors, and evaluate perfusion and graft function in liver transplants are discussed.

Findings

Tumor-specific probes are a promising advancement in FGS with a greater degree of specificity. The current status of tumor-specific probes being evaluated in clinical trials are summarized.

Conclusions and Relevance for Reviews

Relevant discussion of promising tumor-specific probes in pre-clinical development are discussed. Fluorescence-guidance in HPB surgery is relatively new, but current literature shows that the dyes are reliably able to outline desired structures with a variety of dosing, timing, and imaging devices to provide real-time intra-operative anatomic information to surgeons. Development of tumor-specific probes will further advance the field of HPB surgery especially during oncologic resections.

Fluorescence-based cholangiography: preliminary results from the IHU-IRCAD-EAES EURO-FIGS registry

INTRODUCTION

Near-infrared fluorescence cholangiography (NIRF-C) is a popular application of fluorescence image-guided surgery (FIGS). NIRF-C requires near-infrared optimized laparoscopes and the injection of a fluorophore, most frequently Indocyanine Green (ICG), to highlight the biliary anatomy. It is investigated as a tool to increase safety during cholecystectomy. The European registry on FIGS (EURO-FIGS: www.euro-figs.eu ) aims to obtain a snapshot of the current practices of FIGS across Europe. Data on NIRF-C are presented.

METHODS

EURO-FIGS is a secured online database which collects anonymized data on surgical procedures performed using FIGS. Data collected for NIRF-C include gender, age, Body Mass Index (BMI), pathology, NIR device, ICG dose, ICG timing of administration before intraoperative visualization, visualization (Y/N) of biliary structures such as the cystic duct (CD), the common bile duct (CBD), the CD-CBD junction, the common hepatic duct (CHD), Visualization scores, adverse reactions to ICG, operative time, and surgical complications.

RESULTS

Fifteen surgeons (12 European surgical centers) uploaded 314 cases of NIRF-C during cholecystectomy (cholelithiasis n = 249, cholecystitis n = 58, polyps n = 7), using 4 different NIR devices. ICG doses (mg/kg) varied largely (mean 0.28 ± 0.17, median 0.3, range: 0.02-0.62). Similarly, injection-to-visualization timing (minutes) varied largely (mean 217 ± 357; median 57), ranging from 1 min (direct intragallbladder injection in 2 cases) to 3120 min (n = 2 cases). Visualization scores before dissection were significantly correlated, at univariate analysis, with ICG timing (all structures), ICG dose (CD-CBD), device (CD and CD-CBD), surgeon (CD and CD-CBD), and pathology (CD and CD-CBD). BMI was not correlated. At multivariate analysis, pathology and timing remained significant factors affecting the visualization scores of all three structures, whereas ICG dose remained correlated with HD visualization only.

CONCLUSIONS

The EURO-FIGS registry has confirmed a wide disparity in ICG dose and timing in NIRF-C. EURO-FIGS can represent a valuable tool to promote and monitor FIGS-related educational and consensus activities in Europe.

Safe Cholecystectomy Multi-society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy

BACKGROUND

BDI is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI.

METHODS

Literature reviews were conducted for 18 key questions across 6 broad topics around cholecystectomy directed by a steering group and subject experts from 5 surgical societies (Society of Gastrointestinal and Endoscopic Surgeons, Americas Hepato-Pancreato-Biliary Association, International Hepato-Pancreato-Biliary Association, Society for Surgery of the Alimentary Tract, and European Association for Endoscopic Surgery). Evidence-based recommendations were formulated using the grading of recommendations assessment, development, and evaluation methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus.

RESULTS

Consensus was reached on 17 of 18 questions by the guideline development group and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team.

CONCLUSIONS

These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.

A meta-analysis of indocyanine green fluorescence image-guided laparoscopic cholecystectomy for benign gallbladder disease

BACKGROUND

This meta-analysis was conducted to evaluate the effectiveness and safety of indocyanine green fluorescence image-guided laparoscopic cholecystectomy for benign gallbladder disease.

METHODS

Clinical studies were retrieved from PubMed, Embase, Cochrane Library, Medline, and the Web of Science databases. Study-specific effect sizes and their 95 % confidence intervals (CIs) were combined to calculate the pooled values, using fixed-effects or random-effects models.

RESULTS

Eleven studies with combined total of 2221 patients were included. Compared to the control group, the indocyanine green fluorescence imaging-guided group experienced shorter operative time (standardized mean difference [SMD] = -0.30; 95 % CI = -0.45 - -0.15; P < 0.001), shorter biliary anatomy identification time (SMD = -2.34; 95 % CI = -2.58 - -2.10; P < 0.001), lower blood loss (SMD = -0.14; 95 % CI = -0.26 - -0.01; P = 0.035), higher success rate of biliary tract imaging (odds ratio [OR] = 2.37; 95 % CI = 1.09-5.12; P = 0.029), lower rate of conversion to open surgery (OR = 0.10; 95 % CI = 0.04 - 0.28; P < 0.001), shorter hospital stay (SMD = -0.23; 95 % CI = -0.39 - -0.06, P = 0.008), and lower biliary tract imaging costs (SMD = -247.88; 95 % CI, -274.31--221.45, P = 0.000). Postoperative complications did not differ between the groups.

CONCLUSION

This systematic review shows that indocyanine green fluorescence biliary tract imaging is a safe and feasible new way for biliary tract identification in laparoscopic cholecystectomy.

Effectiveness of near-infrared fluorescent cholangiography in the identification of cystic duct-common hepatic duct anatomy in comparison to magnetic resonance cholangio-pancreatography: a preliminary study

INTRODUCTION

Bile duct injury represents the most serious complication of LC, with an incidence of 0.3-0.7% resulting in a significant impact on quality-of-life, overall survival, and frequent medico-legal litigations. Near-infrared fluorescent cholangiography (NIRF-C) represents a novel intra-operative imaging technique that allows a real-time enhanced visualization of the extrahepatic biliary tree by fluorescence. The role of routine use of pre-operative magnetic resonance cholangio-pancreatography (MRCP) to better clarify the biliary anatomy before laparoscopic cholecystectomy is still a matter of debate. The primary aim of this study was to evaluate the effectiveness of NIRF-C in the detection of cystic duct-common hepatic duct anatomy intra-operatively in comparison with pre-operative MRCP.

METHODS

Data from 26 consecutive patients with symptomatic cholelithiasis or chronic cholecystitis, who underwent elective laparoscopic cholecystectomy with intra-operative fluorescent cholangiography and pre-operative MRCP examination between January 2018 and May 2018, were analyzed. Three selected features of the cystic duct-common hepatic duct anatomy were identified and analyzed by the two different imaging methods: insertion of cystic duct, cystic duct-common hepatic duct junction, and cystic duct course.

RESULTS

Fluorescent cholangiography was performed successfully in all twenty-six patients undergoing elective laparoscopic cholecystectomy. The visualization of cystic duct was reported in 23 out of 26 cases, showing an overall diagnostic accuracy of 86.9%. The level of insertion, course, and wall implantation of cystic duct were achieved by NIRF-C with diagnostic accuracy values of 65.2%, 78.3%, and 91.3%, respectively in comparison with MRCP data. No bile duct injuries were reported.

CONCLUSION

Fluorescent cholangiography can be considered a useful imaging diagnostic tool comparable to MRCP for detailed intra-operative visualization of the cystic duct-common hepatic duct anatomy during elective laparoscopic cholecystectomies.

Safe cholecystectomy multi-society practice guideline and state-of-the-art consensus conference on prevention of bile duct injury during cholecystectomy

BACKGROUND

Bile duct injury (BDI) is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI.

METHODS

Literature reviews were conducted for 18 key questions across six broad topics around cholecystectomy directed by a steering group and subject experts from five surgical societies (SAGES, AHPBA IHPBA, SSAT, and EAES). Evidence-based recommendations were formulated using the GRADE methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus.

RESULTS

Consensus was reached on 17 of 18 questions by the Guideline Development Group (GDG) and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team.

CONCLUSION

These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.

Fluorescent Cholangiography in Laparoscopic Cholecystectomy and the Use in Pediatric Patients

Background: Common bile duct (CBD) injury is one of the most serious complications of laparoscopic cholecystectomy and carries an incidence of 0.3%-0.7%. Recently indocyanine green (ICG) fluorescent cholangiography (FC) has been used as an adjunct to identify the biliary tract during adult laparoscopic cholecystectomy, allowing intraoperative identification of biliary anatomy. The objective of this article is to show its successful use in pediatric laparoscopic cholecystectomies. Method: From July 1, 2017, to November 30, 2018, surgeons at John R. Oishei Children's Hospital and Women and Children's Hospital of Buffalo have been utilizing ICG-FC as an adjunct in patients undergoing laparoscopic cholecystectomy. Thirty-one patients undergoing laparoscopic cholecystectomy had 1 mL of dilute ICG (2.5 mg) injected intravenously in the operating room (OR) before trocar placement. Demographics, intraoperative details, and subjective surgeon data were recorded for elective laparoscopic cholecystectomy cases involving ICG. We hypothesize that use of ICG-FC in the pediatric and adolescent patient population is a safe, reliable, and reproducible adjunct for identification of the biliary tree. Secondary outcomes were to identify rate of biliary anatomy identification, utilization ease, and operative times while using ICG technology in pediatric patients. Results: ICG-FC was used in 31 pediatric laparoscopic cholecystectomies performed by 5 surgeons at our institution. Ages ranged from 6 to 18 years. In all cases, the cystic duct-CBD junction was visualized while performing dissection of the triangle of Calot. No intraoperative complications occurred. Conclusions: ICG-FC provides a noninvasive real-time visualization of the extrahepatic biliary tree in children and adolescents. We demonstrate that ICG-FC can successfully be used as an adjunct in pediatric patients and has the potential to facilitate with the dissection and minimize risk of bile duct injuries during pediatric laparoscopic cholecystectomies.

Fluorescence cholangiography enhances surgical residents’ biliary delineation skill for laparoscopic cholecystectomies

BACKGROUND

Laparoscopic cholecystectomy (LC) is a minimally invasive procedure, often performed by surgical residents (SRs). Fluorescence cholangiography (FC) enables real-time identification of biliary anatomy.

AIM

To investigate the benefit of FC for enhancing SRs’ identification skills.

METHODS

Prospective data was collected from January 2018 to June 2018 at our hospital. The study cohorts were the SRs (study group, n = 15) and the surgical staff (SS; control group, n = 9). Participants were assigned to watch videos of LCs with FC from five different patients who had gallbladder disease, and identify structures in the video clips (including cystic duct, common bile duct, common hepatic duct, and cystic artery), first without FC, and then with FC.

RESULTS

In the without-FC phase, the overall misidentification rate by SRs (21.7%) was greater than that of the SS (11.8%; P = 0.018), However, in the FC phase, the two groups did not significantly differ in misidentification rates (23.3% vs 23.3%, P = 0.99). Paired-structure analysis of the without-FC and with-FC phases for the SR group found a significantly higher misidentification rate in the without-FC phase than the with-FC phase (21.9% vs 10.9%; P < 0.01). However, misidentification rates in the with-FC phase did not significantly differ between SRs and SS.

CONCLUSION

FC enhanced identification skills of inexperienced surgeons during LC compared with conventional training. Combined with simulation-based video training, FC is a promising tool for enhancing technical and decision skills of trainees and inexperienced surgeons.

Randomized Trial of Near-infrared Incisionless Fluorescent Cholangiography

BACKGROUND

Incisionless near-infrared fluorescent cholangiography (NIFC) is emerging as a promising tool to enhance the visualization of extrahepatic biliary structures during laparoscopic cholecystectomies.

METHODS

We conducted a single-blind, randomized, 2-arm trial comparing the efficacy of NIFC (n = 321) versus white light (WL) alone (n = 318) during laparoscopic cholecystectomy. Using the KARL STORZ Image1 S imaging system with OPAL1 technology for NIR/ICG imaging, we evaluated the detection rate for 7 biliary structures-cystic duct (CD), right hepatic duct (RHD), common hepatic duct, common bile duct, cystic common bile duct junction, cystic gallbladder junction (CGJ), and accessory ducts -before and after surgical dissection. Secondary calculations included multivariable analysis for predictors of structure visualization and comparing intergroup biliary duct injury rates.

RESULTS

Predissection detection rates were significantly superior in the NIFC group for all 7 biliary structures, ranging from 9.1% versus 2.9% to 66.6% versus 36.6% for the RHD and CD, respectively, with odds ratios ranging from 2.3 (95% CI 1.6-3.2) for the CGJ to 3.6 (1.6-9.3) for the RHD. After dissection, similar intergroup differences were observed for all structures except CD and CGJ, for which no differences were observed. Significant odds ratios ranged from 2.4 (1.7-3.5) for the common hepatic duct to 3.3 (1.3-10.4) for accessory ducts. Increased body mass index was associated with reduced detection of most structures in both groups, especially before dissection. Only 2 patients, both in the WL group, sustained a biliary duct injury.

CONCLUSIONS

In a randomized controlled trial, NIFC was statistically superior to WL alone visualizing extrahepatic biliary structures during laparoscopic cholecystectomy.

REGISTRATION NUMBER

NCT02702843.

Fluorescence or X-ray cholangiography in elective laparoscopic cholecystectomy: a randomized clinical trial

BACKGROUND

Safe laparoscopic cholecystectomy may necessitate biliary imaging, and non-invasive fluorescence cholangiography may have advantages over contrast X-ray cholangiography. This trial compared fluorescence and X-ray cholangiography for visualization of the critical junction between the cystic, common hepatic and common bile ducts.

METHODS

This non-inferiority blinded RCT included patients who had either intraoperative fluorescence cholangiography using 0·05 mg/kg indocyanine green or X-ray cholangiography during elective laparoscopic cholecystectomy.

RESULTS

Between March 2015 and August 2018, a total of 120 patients were randomized (60 in each group). There were no drop-outs and 30-day follow-up data were available for all patients. In intention-to-treat analysis, there was no difference between the fluorescence and X-ray cholangiography groups in ability to visualize the critical junction (49 of 60 versus 51 of 60 respectively; P = 0·230). Fluorescence cholangiography was faster by a few minutes: median 2·0 (range 0·5-5·0) versus 4·8 (1·3-17·6) min (P < 0·001).

CONCLUSION

Fluorescence cholangiography was confirmed to be non-inferior to X-ray cholangiography in visualizing the critical junction during laparoscopic cholecystectomy. Registration number: NCT02344654 ( http://www.clinicaltrials.gov).

Novel near-infrared fluorescent probe for live cell imaging

Near infrared (NIR) fluorescent probes play a crucial role in biological system imaging. A novel NIR fluorescent probe, IR787, was designed in the present study. Compared with indocyanine green (ICG), IR787 showed lower background fluorescent interference and higher fluorescence enhancement. Fluorescence intensities were detected by a Cary Eclipse fluorescence spectrophotometer. The interference of intracellular ions (Cu²⁺, Ca²⁺, Mg²⁺ and Zn²⁺) on the measurement was negligible, which indicated a good photostability of IR787. MTT assay demonstrated that cell viability of human lung adenocarcinoma epithelial cell line A549 was not significantly affected by the use of the IR787 probe compared with the ICG probe. This result suggested that the IR787 probe was safe for in vitro cell imaging. In vitro NIR optical imaging experiments further revealed cellular uptake and strong intracellular NIR fluorescence of the IR787 probe in A549 cells. The excitation wavelength was 787 nm for IR787. Compared with the previously reported NIR fluorescent probe ICG, the IR787 NIR fluorescent probe had improved prospects for intracellular imaging. IR787 may play a pivotal role in the understanding cell biology, pharmacology and disease diagnosis.

[Fluorescence-guided detection of lymph node metastases of gastrointestinal tumors]

A correct lymph node (LN) staging is essential in oncological surgery. Indocyanine green (ICG) near-infrared fluorescence (NIRF) guided sentinel lymph node (SLN) navigation is a relatively novel technique. The aim of this review is to analyze the impact of ICG-NIRF on identification of LN metastases of gastrointestinal tumors. The Scopus and PubMed/MEDLINE literature databases were searched and 20 studies were included. The ICG-NIRF navigation of LN has been shown to enable and improve LN detection in gastrointestinal tumors; however, the mean detection, sensitivity, accuracy and false negative rates show substantial variation. This could be due to both the heterogeneous techniques applied and to the low retention of ICG by lymph nodes. Fluorescence imaging to identify LN drainage is a promising tool to improve oncological outcomes. Nonetheless, the technique requires further development in terms of hardware, software and fluorophores, which are currently being investigated.

[Intraoperative fluorescence angiography and cholangiography with indocyanine green in hepatobiliary surgery]

Intraoperative fluorescence angiography and cholangiography with indocyanine green (ICG) are increasingly used in routine hepatobiliary surgery. Its usage is manifold. It improves and facilitates navigation especially in minimal invasive and robotic surgery and therefore increases the safety of the surgical intervention. In laparoscopic cholecystectomy for example, the bileduct anatomy can be easily visualized, even in complicated cholecystitis or anatomical variants without being too time consuming. ICG fluorescence also enables the visualization of vascular structures and perfusion. Anatomical liver resections, for example in hepatocellular carcinoma (HCC), can be performed easily as liver segments and territories can be identified. Anatomical resection is becoming more important, e.g. in the treatment of HCC. Another useful application is the intraoperative detection of bile leakages after liver resection. In particular, the intraoperative control of a biliodigestive anastomosis is possible with ICG fluorescence cholangiography and therefore reduces morbidity. Even primary and secondary liver tumors can be detected with ICG fluorescence. Whereas well-differentiated HCCs homogeneously take up ICG, poorly differentiated HCCs and metastases do not: however, in these cases the adjacent liver parenchyma stores ICG more intensively than healthy liver tissue, which creates a ring-like fluorescence pattern. To conclude, the use of ICG fluorescence in hepatobiliary surgery is diverse but in Germany it is still at the beginning compared to other countries.

Intraoperative detection of the remnant cystic duct during robot-assisted surgery using near-infrared fluorescence imaging: a case report

Background

Post cholecystectomy syndrome is characterized as recurrence of symptoms as experienced before cholecystectomy. In rare cases, a remnant cystic duct is causing these symptoms and occasionally surgical resection is performed. During surgery, visualization of the biliary ducts could be difficult due to inflammation and dense adhesions.

Case presentation

In this article, we presented a 36-year old woman with post-cholecystectomy syndrome in which we evaluated the feasibility of near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) for visualization of the remnant cystic and common bile duct during robot-assisted surgery. Intraoperative visualization of the remnant biliary duct and other important structures was feasible, and resection of the remnant cystic duct was successfully performed under fluorescence guidance, without any complications.

Conclusions

NIR fluorescence imaging of the biliary ducts using ICG does not prolong the operating time, and could potentially decrease the operation time in difficult procedures, because of easy and fast detection of the biliary tract. Furthermore, it is a non-hazardous and non-invasive technique, as it does not require use of radiation and cannot cause bile duct injury. This case illustrated that ICG NIR fluorescence imaging during difficult robot-assisted surgical procedures of the bile ducts is effective and therefore highly recommended.

Electronic supplementary material

The online version of this article (10.1186/s12893-019-0567-8) contains supplementary material, which is available to authorized users.

Identification of aberrant subvesical bile duct by using intraoperative fluorescent cholangiography: A case report

•

Aberrant subvesical bile duct poses risk of bile duct injury during cholecystectomy.

•

Intraoperative fluorescent cholangiography (IFC) could allow us to identify a fine minute bile duct.

•

IFC is one of a promising technique to improve the safety of cholecystectomy further.

Introduction

Aberrant subvesical bile ducts are rare structural anomaly located in the peri-hepatic gallbladder fossa. This duct poses the risk for intraoperative bile duct injury resulting in clinically relevant bile leakage.

Presentation of case

Aberrant subvesical bile duct was detected by preoperative magnetic resonance cholangiopancreatography in a 52-year old woman with gallbladder polypoid tumor harboring the risk to be gallbladder cancer. During open cholecystectomy with full thickness dissection, the aberrant duct was identified by intraoperative fluorescent cholangiography (IFC), and dissected safely.

Discussion

Aberrant subvesical bile ducts are mostly found unexpectedly as intra and/or postoperative bile leakage, and remain an important cause of bile duct injuries after laparoscopic cholecystectomy. IFC, which offers real-time imaging of biliary anatomy, has a potential to overcome these problems.

Conclusion

We performed cholecystectomy by using IFC to identify the aberrant subvesical bile duct. To the best of our knowledge, this is the first report showing the fluorescence image of an aberrant subvesical bile duct in a state of nature.

Incisionless fluorescent cholangiography (IFC): a pilot survey of surgeons on procedural familiarity, practices, and perceptions

BACKGROUND

Incisionless fluorescent cholangiography (IFC) has recently been proven feasible, safe, and efficacious as an intraoperative procedure to help identify extrahepatic bile ducts during laparoscopic cholecystectomies (LC). We conducted a pilot survey of 51 surgeons attending an international conference who perform endoscopic cholecystectomies to identify their typical LC practices, and perceptions of IFC.

METHODS

An international panel of ten IFC experts, all with > 500 prior IFC procedures and related research publications, convened during the 4th International Congress of Fluorescence-Guided Surgery in Boca Raton, Florida in February 2017. The panel was charged with developing questions about LC practices and experience with IFC, and perceptions regarding its advantages, barriers to use, and indications. These questions then were asked to other congress attendees during one of the didactic sessions using an online polling application. Attendees, who ranged from zero to considerable experience performing IFC, accessed the survey via their portable devices.

RESULTS

Of the 51 survey participants, 51% were from North America; 77% identified themselves as general/minimally invasive surgeons, and roughly 60% performed under 50 cholecystectomies/year. Only 12% performed routine intraoperative cholangiography (IOC), while 72.3% routinely performed critical safety reviews. Thirty-five percent estimated that their institution's laparoscopic-to-open surgery conversion rate was > 1% during LC. Roughly 95% of respondents felt that surgeons should have access to a noninvasive method for evaluating extrahepatic biliary structures; 84% felt that the most advantageous characteristic of IFC is the lack of any biliary-tree incision; and 93.3% felt that IFC would have considerable educational value in surgical training programs; and 78% felt that any surgeon who performs LC could benefit.

CONCLUSIONS

Surgeons who participated in our survey overwhelmingly recommended the routine use of IFC during laparoscopic cholecystectomy as a complimentary imaging technique. Prospective randomized clinical trials remain necessary to determine whether IFC reduces the incidence of bile duct injuries and other LC complications.

Safe laparoscopic cholecystectomy: A systematic review of bile duct injury prevention

BACKGROUND

Since the introduction of laparoscopic cholecystectomy (LC), a substantial increase in bile duct injury (BDI) incidence was noted. Multiple methods to prevent this complication have been developed and investigated. The most suitable method however is subject to debate. In this systematic review, the different modalities to aid in the safe performance of LC and prevent BDI are delineated.

MATERIALS AND METHODS

A systematic search for articles describing methods for the prevention of BDI in LC was conducted using EMBASE, Medline, Web of science, Cochrane CENTRAL and Google scholar databases from inception to 11 June 2018.

RESULTS

90 studies were included in this systematic review. Overall, BDI preventive techniques can be categorized as dedicated surgical approaches (Critical View of Safety (CVS), fundus first, partial laparoscopic cholecystectomy), supporting imaging techniques (intraoperative radiologic cholangiography, intraoperative ultrasonography, fluorescence imaging) and others. Dedicated surgical approaches demonstrate promising results, yet limited research is provided. Intraoperative radiologic cholangiography and ultrasonography demonstrate beneficial effects in BDI prevention, however the available evidence is low. Fluorescence imaging is in its infancy, yet this technique is demonstrated to be feasible and larger trials are in preparation.

CONCLUSION

Given the low sample sizes and suboptimal study designs of the studies available, it is not possible to recommend a preferred method to prevent BDI. Surgeons should primarily focus on proper dissection techniques, of which CVS is most suitable. Additionally, recognition of hazardous circumstances and knowledge of alternative techniques is critical to complete surgery with minimal risk of injury to the patient.

Fluorescence Imaging for Minimally Invasive Cancer Surgery

This article demonstrates surgical techniques of intraoperative fluorescence imaging using indocyanine green, focusing on its application in minimally invasive hepatobiliary and pancreatic surgery. In this area, indocyanine green fluorescence imaging has been applied to liver cancer identification, fluorescence cholangiography, delineation of hepatic segments, and fluorescence angiography and perfusion assessment. The development of target-specific fluorophores and advances in imaging technology will allow real-time intraoperative fluorescence imaging to develop into an essential intraoperative navigation tool. This property may contribute to enhancing both accuracy and safety of minimally invasive surgery.

A practical guide for the use of indocyanine green and methylene blue in fluorescence-guided abdominal surgery

Near-infrared (NIR) fluorescence imaging is gaining clinical acceptance over the last years and has been used for detection of lymph nodes, several tumor types, vital structures and tissue perfusion. This review focuses on NIR fluorescence imaging with indocyanine green and methylene blue for different clinical applications in abdominal surgery with an emphasis on oncology, based on a systematic literature search. Furthermore, practical information on doses, injection times, and intraoperative use are provided.

Near-infrared fluorescent cholangiography - real-time visualization of the biliary tree during elective laparoscopic cholecystectomy

BACKGROUND

The purpose was to evaluate the efficacy of near-infrared fluorescent cholangiography (FC) in real-time visualization of the biliary tree during elective laparoscopic cholecystectomy.

METHODS

Fifty consecutive elective laparoscopic cholecystectomies were performed with fluorescent cholangiography. FC was performed at three time points: following exposure of Calot's triangle, prior to any dissection; and after partial and complete dissection of Calot's triangle.

RESULTS

The cystic duct (CD) was identified successfully by FC in 43 of 50 patients (86%) and in 45 of 50 patients (90%) before and after Calot's dissection respectively (p > 0.05). The common hepatic duct (CHD) and the common bile duct (CBD) were identified successfully in 12 of 50 patients (24%) and in 33 of 50 patients (66%) before Calot's dissection respectively and in 26 of 50 patients (52%) and in 47 of 50 patients (94%) after complete Calot's dissection (p = 0.007 and p = 0.001, respectively). Significant differences were observed for CBD visualization rate, in relation to BMI after Calot's dissection (p < 0.05) and history of cholecystitis, before Calot's dissection (p = 0.017). No bile duct injuries were reported.

CONCLUSION

Fluorescent cholangiography can be considered as a useful tool for intra-operative visualization of the biliary tree during laparoscopic cholecystectomies.

Optimizing the image of fluorescence cholangiography using ICG: a systematic review and ex vivo experiments

Background

Though often only briefly described in the literature, there are clearly factors that have an influence on the fluorescence intensity, and thereby the usefulness of the technique. This article aims to provide an overview of the factors influencing the fluorescence intensity of fluorescence imaging with Indocyanine green, primarily focussed on NIRF guided cholangiography.

Methods

A systematic search was conducted to gain an overview of currently used methods in NIRF imaging in laparoscopic cholecystectomies. Relevant literature was searched to gain advice on what methods to use. Ex vivo experiments were performed to assess various factors that influence fluorescence intensity and whether the found clinical advices can be confirmed.

Results

ICG is currently the most widely applied fluorescent dye. Optimal ICG concentration lies between 0.00195 and 0.025 mg/ml, and this dose should be given as early as achievable—but maximum 24 h—before surgery. When holding the laparoscope closer and perpendicular to the dye, the signal is most intense. In patients with a higher BMI and/or cholecystitis, fluorescence intensity is lower, but NIRF seems to be more helpful. There are differences between various marketed fluorescence systems. Also, no uniform method to assess fluorescence intensity is available yet.

Conclusions

This study identified and discussed several factors that influence the signal of fluorescence cholangiography. These factors should be taken into account when using NIRF cholangiography. Also, surgeons should be aware of new dyes and clinical systems, in order to benefit most from the potential of NIRF imaging.

Electronic supplementary material

The online version of this article (10.1007/s00464-018-6233-x) contains supplementary material, which is available to authorized users.

Prospective Evaluation of Precision Multimodal Gallbladder Surgery Navigation: Virtual Reality, Near-infrared Fluorescence, and X-ray-based Intraoperative Cholangiography

OBJECTIVE

We aimed to prospectively evaluate NIR-C, VR-AR, and x-ray intraoperative cholangiography (IOC) during robotic cholecystectomy.

BACKGROUND

Near-infrared cholangiography (NIR-C) provides real-time, radiation-free biliary anatomy enhancement. Three-dimensional virtual reality (VR) biliary anatomy models can be obtained via software manipulation of magnetic resonance cholangiopancreatography, enabling preoperative VR exploration, and intraoperative augmented reality (AR) navigation.

METHODS

Fifty-eight patients were scheduled for cholecystectomy for gallbladder lithiasis. VR surgical planning was performed on virtual models. At anesthesia induction, indocyanine green was injected intravenously. AR navigation was obtained by overlaying the virtual model onto real-time images. Before and after Calot triangle dissection, NIR-C was obtained by turning the camera to NIR mode. Finally, an IOC was performed. The 3 modality performances were evaluated and image quality was assessed with a Likert-scale questionnaire.

RESULTS

The three-dimensional VR planning enabled the identification of 12 anatomical variants in 8 patients, of which only 7 were correctly reported by the radiologists (P = 0.037). A dangerous variant identified at VR induced a "fundus first" approach. The cystic-common bile duct junction was visualized before Calot triangle dissection at VR in 100% of cases, at NIR-C in 98.15%, and in 96.15% at IOC.Mean time to obtain relevant images was shorter with NIR-C versus AR (P = 0.008) and versus IOC (P = 0.00000003). Image quality scores were lower with NIR-C versus AR (P = 0.018) and versus IOC (P < 0.0001).

CONCLUSIONS

This high-tech protocol illustrates the multimodal imaging of biliary anatomy towards precision cholecystectomy. Those visualization techniques could complement to reduce the likelihood of biliary injuries (NCT01881399).