A Pilot Study for Biliary Atresia Diagnosis: Fluorescent Imaging of Indocyanine Green in Stool

BACKGROUND

Biliary atresia is the most common cause of obstructive jaundice in infants and conventional cholangiography is the current diagnostic gold standard. Fluorescent cholangiography with indocyanine green can enhance biliary tree visualization during surgery because it is exclusively excreted into the bile ducts and eventually into the intestine. Therefore, we hypothesized that indocyanine green presence in stool could confirm bile duct patency in infants.

METHODS

A prospective single center cohort study was performed on infants (age ≤ 12 months) with and without jaundice after obtaining IRB approval. Indocyanine green was administered intravenously (0.1 mg/kg). Soiled diapers collected post-injection were imaged for fluorescence.

RESULTS

After indocyanine green administration, fluorescence was detected in soiled diapers for control patients (n = 4, x = 14 h22 m post-injection) and jaundiced patients without biliary atresia (n = 11, x = 13 h28 m post-injection). For biliary atresia patients (n = 7), post-injection soiled diapers before and after Kasai portoenterostomy were collected. Fluorescence was not detected in stool from 6 of 7 biliary atresia patients. As a test, indocyanine green detection in stool was 97% accurate for assessing biliary patency.

CONCLUSION

Fluorescent Imaging for Indocyanine Green (FIInd Green) in stool is a fast and accurate approach to assess biliary patency non-invasively in infants.

LEVEL OF EVIDENCE

Level III.

Investigation of the optimal indocyanine green dose in real-time fluorescent cholangiography during laparoscopic cholecystectomy with an ultra-high-definition 4K fluorescent system: a randomized controlled trial

This study aimed to investigate the indocyanine green (ICG) dose in real-time fluorescent cholangiography during laparoscopic cholecystectomy (LC) with a 4K fluorescent system. A randomized controlled clinical trial was conducted in patients who underwent LC for treatment of cholelithiasis. Using the OptoMedic 4K fluorescent endoscopic system, we compared four different doses of ICG (1, 10, 25, and 100 µg) administered intravenously within 30 min preoperatively and evaluated the fluorescence intensity (FI) of the common bile duct and liver background and the bile-to-liver ratio (BLR) of the FI at three timepoints: before surgical dissection of the cystohepatic triangle, before clipping the cystic duct, and before closure. Forty patients were randomized into four groups, and 33 patients were fully analyzed, with 10 patients in Group A (1 µg), 7 patients in Group B (10 µg), 9 patients in Group C (25 µg), and 7 patients in Group D (100 µg). The preoperative baseline characteristics were compared among groups (p > 0.05). Group A showed no or minimal FI in the bile duct and liver background, while Group D showed extremely high FIs in the bile duct and in the liver background at the three timepoints. Groups B and C presented with visible FI in the bile duct and low FI in the liver background. With increasing ICG doses, the FIs in the liver background and bile duct gradually increased at the three timepoints. The BLR, however, showed no increasing trend with an increasing ICG dose. A relatively high BLR on average was found in Group B, without a significant difference compared to the other groups (p > 0.05). An ICG dose ranging from 10 to 25 µg by intravenous administration within 30 min preoperatively was appropriate for real-time fluorescent cholangiography in LC with a 4K fluorescent system. Registration: This study was registered in the Chinese Clinical Trial Registry (ChiCTR No: ChiCTR2200064726).

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.

Indocyanine green fluorescent cholangiography improves the clinical effects of difficult laparoscopic cholecystectomy

BACKGROUND

Near-infrared fluorescent cholangiography (NIRFC) with indocyanine green (ICG) as the developer yields clear visualization of the extrahepatic bile ducts and is effective in identifying key structures. Here, we analyzed and compared the surgical outcomes of fluorescent and conventional laparoscopy in cholecystectomy of various difficulties and then assessed the value of NIRFC.

MATERIALS AND METHODS

This retrospective study collected clinical data from partial patients who underwent laparoscopic cholecystectomy (LC) at the Department of Hepatobiliary and Pancreatic Surgery, Zhongnan Hospital of Wuhan University between 2020 and 2021. The study subjects were classified into ICG-assisted and white-light laparoscopy. Two cohorts with homogeneous baseline status were selected based on 1:1 ratio propensity score matching (PSM). Multivariate logistic regression analysis was performed to predict independent risk factors for LC difficulty. Thereafter, the matched cases were classified into difficult and easy subgroups by combining difficulty score and gallbladder disease type, and then the surgical outcomes of the two groups were compared.

RESULTS

This study included a total of 624 patients. The patients were classified into the ICG group (n = 218) and the non-ICG group (n = 218) after a 1:1 ratio PSM. Our data showed significant differences between the groups in operative time (P = 0.020), blood loss (P = 0.016), length of stay (P = 0.036), and adverse reaction (P = 0.023). Stratified analysis demonstrated that ICG did not significantly improve the surgical outcomes in simple cases (n = 208). On the other hand, in difficult cases (n = 228), NIRFC shortened operative time (P = 0.003) and length of stay (P = 0.015), reduced blood loss (P = 0.028) and drain placement rate (P = 0.015), and had fewer adverse reactions (P = 0.023). The data showed that five cases were converted to laparotomy while two cases had minor bile leaks in the non-ICG group. There was no bile duct injury (BDI) in all the cases. Furthermore, high BMI, history of urgent admission and abdominal surgery, palpable gallbladder, thickened wall, and pericholecystic collection were risk factors for surgical difficulty.

CONCLUSION

ICG-assisted NIRFC provides real-time biliary visualization. In complicated conditions such as acute severe inflammation, dense adhesions, and biliary variants, the navigating ability of fluorescence can enhance the operation progress, reduce the possibility of conversion or serious complications, and improve the efficiency and safety of difficult LC.

Real-time fluorescent cholangiography with indocyanine green in laparoscopic cholecystectomy: a randomized controlled trial to establish the optimal indocyanine green dose within 30 min preoperatively

PURPOSE

To establish the optimal dose of indocyanine green (ICG) to administer intravenously 30 min before laparoscopic cholecystectomy (LC).

METHODS

In this randomized controlled trial (RCT), patients undergoing LC for cholecystitis, cholelithiasis, and/or cholecystic polyps were randomized into four groups given four different ICG doses (0.025, 0.1, 0.25, 2.5 mg). Using OptoMedic endoscopy combined with a near-infrared fluorescent imaging system, we evaluated the fluorescence intensity (FI) of the common bile duct and liver at three timepoints: before surgical dissection of the cystohepatic triangle, before clipping of the cystic duct, and before closure. The bile duct-to-liver ratio (BLR) of the FI was analyzed to assess the cholangiography effect.

RESULTS

Sixty-four patients were allocated to one of four groups, with 40 patients included in the final analysis. Generally, with increasing ICG doses, the levels of FI in the bile duct and liver increased gradually at each of the three timepoints. Before surgical dissection of the cystohepatic triangle, 0.1-mg ICG showed the highest BLR (F = 3.47, p = 0.0259). Before clipping the cystic duct and before closure, the 0.025- and 0.1-mg groups showed a higher BLR than the 0.25- and 2.5-mg groups (p < 0.05). When setting the ideal cholangiography at a BLR ≥ 1, ≥ 3, or ≥ 5, the 0.1-mg group showed the highest qualified case number at the three timepoints.

CONCLUSIONS

The intravenous administration of 0.1-mg ICG, 30 min before LC, is significantly better for fluorescent cholangiography of the extrahepatic biliary structures before dissection and clipping of the cystohepatic triangle.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Registry (ChiCTR) (ChiCTR2200057933).

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.

Initial experience of intraoperative fluorescent cholangiography during laparoscopic cholecystectomy: A retrospective study

Background

Fluorescent cholangiography (FC) during laparoscopic cholecystectomy (LC) is a novel method to facilitate real-time visualization of extrahepatic biliary structures that avoiding risk of bile duct injury. Aims of this study are to investigate the feasibility and the safety of FC during LC.

Method

We evaluated the outcomes of FC during elective LC at our hospital from August 2017 to April 2018. Fifty-five patients who underwent FC during elective LC were enrolled in this study. Demographic and peri-operative data were recorded and analyzed. The primary endpoints were visualization rate of FC during LC. The secondary endpoint was the optimal conditions and technical details for FC included to detect any potential adverse event.

Results

The visualization rate after FC of the cystic duct, common hepatic duct and common bile duct were increased significantly compared to before FC. The identification rate of the cystic duct and common bile duct were not associated with BMI and history of acute cholecystitis.

Conclusions

FC enabled real-time visualization of extrahepatic biliary structures during LC. FC appears to be a safe and efficient approach for elective LC.

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Bile duct injury is one of the most complication of laparoscopic cholecystectomy.

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Fluorescent cholangiography is offer real-time detection of the biliary anatomy.

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Cholangiogram was associated with a low incidence of bile duct injury.

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.

Fluorescent cholangiography significantly improves patient outcomes for laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) is the most common elective abdominal surgery in the USA, with over 750,000 performed annually. Fluorescent cholangiography (FC) using indocyanine green dye (ICG) permits identification of extrahepatic biliary structures to facilitate dissection without requiring cystic duct cannulation. Achieving the "critical view of safety" with assistance of ICG cholangiogram may support identification of anatomy, safely reduce conversion to open procedures, and decrease operative time. We assess the utility of FC with respect to anatomic visualization during LC and its effects on patient outcomes.

METHODS

A retrospective review of a prospectively maintained database identified patients undergoing laparoscopic cholecystectomy at a single academic center from 2013 to 2019. Exclusion criteria were primary open and single incision cholecystectomy. Patient factors included age, sex, BMI, and Charlson Comorbidity Index. Outcomes included operative time, conversion to open procedure, length of stay (LOS), mortality rate, and 30-day complications. A multivariable logistic regression was performed to determine independent predictors for open conversion.

RESULTS

A total of 1389 patients underwent laparoscopic cholecystectomy. 69.8% were female; mean age 48.6 years (range 15-94), average BMI 29.4 kg/m² (13.3-55.6). 989 patients (71.2%) underwent LC without fluorescence and 400 (28.8%) underwent FC with ICG. 30-day mortality detected 2 cases in the non-ICG group and zero with ICG. ICG reduced operative time by 26.47 min per case (p < 0.0001). For patients with BMI ≥ 30 kg/m², operative duration for ICG vs non-ICG groups was 75.57 vs 104.9 min respectively (p < 0.0001). ICG required conversion to open at a rate of 1.5%, while non-ICG converted at a rate of 8.5% (p < 0.0001). Conversion rate remained significant with multivariable analysis (OR 0.212, p = 0.001). A total of 19 cases were aborted (1.35%), 8 in the ICG group (1.96%) and 11 in the non-ICG group (1.10%), these cases were not included in LC totals. Average LOS was 0.69 vs 1.54 days in the ICG compared to non-ICG LCs (p < 0.0001), respectively. Injuries were more common in the non-ICG group, with 9 patients sustaining Strasberg class A injuries in the non-ICG group and 2 in the ICG group. 1 CBDI occurred in the non-ICG group. There was no significant difference in 30-day complication rates between groups.

CONCLUSION

ICG cholangiography is a non-invasive adjunct to laparoscopic cholecystectomy, leading to improved patient outcomes with respect to operative times, decreased conversion to open procedures, and shorter length of hospitalization. Fluorescence cholangiography improves visualization of biliary anatomy, thereby decreasing rate of CBDI, Strasberg A injuries, and mortality. These findings support ICG as standard of care during laparoscopic cholecystectomy.

Intracholecystic administration of indocyanine green for fluorescent cholangiography during laparoscopic cholecystectomy-A two-case report

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It is difficult to visualize extra-hepatic biliary anatomy clearly because of long-presence of ICG in liver when administered intravenously.

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Intracholecystic ICG injection illuminates extra-hepatic biliary tree preferentially thus reducing background hepatic noise.

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Surgeons can experience more satisfaction with the use of fluorescent cholangiography during laparoscopic cholecystectomy when the intracystic route of ICG administration is utilized.

Introduction

The utility of intracystic administration of indocyanine green for near-infrared fluorescent cholangiography in acute calculous cholecystitis initially treated with percutaneous transhepatic gallbladder drainage (PTGBD) was described in this report.

Presentation of case

Two cases who underwent near-infrared fluorescent cholangiography guided interval laparoscopic cholecystectomy two weeks post-PTGBD were studied retrospectively. Both patients were diagnosed with moderate acute calculous cholecystitis based on diagnostic criteria of the Tokyo guidelines. Two routes of indocyanine green administration were utilized during surgery, first through direct intracystic administration through PTGBD tube (5 ml of 12.5 mg ICG) to achieve critical view of safety and then intravenous administration (1 ml of 2.5 mg ICG) to visualize cystic artery.

Discussion

Both patients had critical view of safety visualized clearly with ICG with the operation time of 84 and 125 min in cases 1 and 2, respectively without any intra or postoperative complications.

Conclusion

In comparison with intravenous ICG administration, trans-PTGBD ICG route can provide better signal-to-noise ratio by avoiding hepatic fluorescence and thus increasing the bile duct to liver contrast. However, ICG may enter the lymphatic system through necrotic and inflammatory gallbladder mucosa, of which lymph spillage during gallbladder dissection can obscure the fluorescent view.

Optimal timing of preoperative indocyanine green administration for fluorescent cholangiography during laparoscopic cholecystectomy using the PINPOINT® Endoscopic Fluorescence Imaging System

INTRODUCTION

The PINPOINT® Endoscopic Fluorescence Imaging System (Novadaq, Mississauga, Canada) allows surgeons to visualize the bile ducts during laparoscopic cholecystectomy. Surgeons can continue operation while confirming the bile ducts' fluorescence with a bright-field/color image. However, strong fluorescence of the liver can interfere with the surgery. Here, we investigated the optimal timing of indocyanine green administration to allow fluorescent cholangiography to be performed without interference from the liver fluorescence.

METHODS

A total of 72 patients who underwent laparoscopic cholecystectomy were included in this study. The timing of indocyanine green administration was set immediately before surgery and at 3, 6, 9, 12, 15, 18, and 24 h before surgery. The luminance intensity ratios of gallbladder/liver, cystic duct/liver, and common bile duct/liver were measured using the ImageJ software (National Institutes of Health, Bethesda, USA). Visibility of the gallbladder and bile ducts was classified into three categories (grades A, B, and C) based on the degree of visibility in contrast to the liver.

RESULTS

The luminance intensity ratio for the gallbladder/liver, cystic duct/liver, and common bile duct/liver was ≥1 in the 15-, 18-, and 24-h groups. The proportion of cases in which evaluators classified the visibility of the gallbladder and bile ducts as grade A (best visibility) reached a peak in the 15-h group and decreased thereafter.

CONCLUSIONS

In the present study, the optimal timing of indocyanine green administration for fluorescent cholangiography during laparoscopic cholecystectomy using the PINPOINT Endoscopic Fluorescence Imaging System was 15 h before surgery.

Application of fluorescent cholangiography during single-incision laparoscopic cholecystectomy for cholecystitis with a right-sided round ligament: Preliminary experience

An 82-year-old woman was diagnosed with cholecystitis with a right-sided round ligament. We planned a single-incision laparoscopic cholecystectomy. Based on the findings of fluorescent cholangiography, the running course of the common bile duct was confirmed before dissection of Calot's triangle, and the confluence between the cystic duct and the common bile duct was exposed after the dissection of Calot's triangle. The planned surgery was successful. The operative time and intraoperative blood loss were 157 min and 2 mL, respectively. The patient was discharged from our hospital 3 days after surgery. Application of fluorescent cholangiography during a laparoscopic cholecystectomy for the patients with a right-sided round ligament should be widely accepted.

Near-infrared fluorescence laparoscopy of the cystic duct and cystic artery: first experience with two new preclinical dyes in a pig model

Background

Imaging techniques that enhance visualisation of the anatomy may help prevent bile duct injury. Near-Infrared Fluorescence Imaging is such a technique. Previous experiments with ICG have shown that illumination of the extra-hepatic bile ducts is feasible. Yet, there is room for improvement in the visualisation of the target as compared to the background. Experiments with IRDye^® 800CW show promising results. However, this dye is too expensive for routine clinical use. The aim of this study is to test the first applicability of two newly developed preclinical dyes regarding intraoperative imaging of the cystic duct and cystic artery, compared with IRDye^® 800CW.

Methods

Laparoscopic cholecystectomy was performed in three pigs, using a laparoscopic fluorescence imaging system. Each pig received 6 mg of one of the fluorescent dyes (1 mg/mL; IRDye^® 800CW, IRDye^® 800BK or IRDye^® 800NOS) by intravenous injection. Intraoperative recognition of the biliary system and cystic artery was registered at set time points. All procedures were digitally recorded, and the target to background ratio (TBR) was determined to assess the fluorescence signal.

Results

With all three fluorescent dyes, the cystic artery was directly visualised. For the visualisation of the cystic duct, 15, 34 and 30 min were needed using IRDye^® 800BK, IRDye^® 800NOS and IRDye^® 800CW, respectively. The maximum TBR of the cystic duct was the highest with IRDye^® 800NOS (4.20) after 36 min, compared to 2.45 for IRDye^® 800BK and 2.15 for IRDye^® 800CW, both after 45 min. There were no adverse events.

Conclusion

IRDye^® 800BK and IRDye^® 800NOS seem to be good alternatives for IRDye^® 800CW for the visualisation of the cystic duct and cystic artery in pigs.

Clinical value and pitfalls of fluorescent cholangiography during single-incision laparoscopic cholecystectomy

PURPOSE

To clarify the clinical value and pitfalls of fluorescent cholangiography (FC) during single-incision laparoscopic cholecystectomy (SILC).

METHODS

Our SILC procedure utilized the SILS-Port with additional 5-mm forceps through an umbilical incision. A laparoscopic fluorescent imaging system developed by Karl Storz Endoskope was utilized for fluorescent cholangiography.

RESULTS

We performed fluorescent cholangiography during SILC in 21 patients. All procedures were completed successfully without biliary injury. The detectability of the running course of the cystic duct, the confluence between the cystic duct and the common hepatic duct, and the common hepatic duct before the dissection in Calot's triangle was 47.6, 71.4, and 81.0 %, respectively. The detectability of biliary structures was worse in 9 obese patients (body mass index ≥ 25.0 kg/m²) than in 12 non-obese patients. The mean operative time for the patients in whom fluorescent cholangiography could identify the running course of the cystic duct before dissection in Calot's triangle (68 ± 16 min) was shorter than that for the other patients (91 ± 35 min; p = 0.037).

CONCLUSIONS

Fluorescent cholangiography can prevent biliary injury during SILC and facilitate SILC. Obesity is the most important factor that can prevent identification of biliary structures under fluorescent cholangiography.

Utility of fluorescent cholangiography during laparoscopic cholecystectomy: A systematic review

AIM: To verify the utility of fluorescent cholangiography for more rigorous identification of the extrahepatic biliary system.

METHODS: MEDLINE and PubMed searches were performed using the key words “fluorescent cholangiography”, “fluorescent angiography”, “intraoperative fluorescent imaging”, and “laparoscopic cholecystectomy” in order to identify relevant articles published in English, French, German, and Italian during the years of 2009 to 2014. Reference lists from the articles were reviewed to identify additional pertinent articles. For studies published in languages other than those mentioned above, all available information was collected from their English abstracts. Retrieved manuscripts (case reports, reviews, and abstracts) concerning the application of fluorescent cholangiography were reviewed by the authors, and the data were extracted using a standardized collection tool. Data were subsequently analyzed with descriptive statistics. In contrast to classic meta-analyses, statistical analysis was performed where the outcome was calculated as the percentages of an event (without comparison) in pseudo-cohorts of observed patients.

RESULTS: A total of 16 studies were found that involved fluorescent cholangiography during standard laparoscopic cholecystectomies (n = 11), single-incision robotic cholecystectomies (n = 3), multiport robotic cholecystectomy (n = 1), and single-incision laparoscopic cholecystectomy (n = 1). Overall, these preliminary studies indicated that this novel technique was highly sensitive for the detection of important biliary anatomy and could facilitate the prevention of bile duct injuries. The structures effectively identified before dissection of Calot’s triangle included the cystic duct (CD), the common hepatic duct (CHD), the common bile duct (CBD), and the CD-CHD junction. A review of the literature revealed that the frequencies of detection of the extrahepatic biliary system ranged from 71.4% to 100% for the CD, 33.3% to 100% for the CHD, 50% to 100% for the CBD, and 25% to 100% for the CD-CHD junction. However, the frequency of visualization of the CD and the CBD were reduced in patients with a body mass index > 35 kg/m² relative to those with a body mass index < 35 kg/m² (91.0% and 64.0% vs 92.3% and 71.8%, respectively).

CONCLUSION: Fluorescent cholangiography is a safe procedure enabling real-time visualization of bile duct anatomy and may become standard practice to prevent bile duct injury during laparoscopic cholecystectomy.

Fluorescent imaging of the biliary tract during laparoscopic cholecystectomy. Ann Surg Innov Res. 2014;8:5. [PMID: 25317203 PMCID: PMC4196113 DOI: 10.1186/s13022-014-0005-7]

The introduction of laparoscopic cholecystectomy was associated with increased incidences of bile duct injury. The primary cause appears to be misidentification of the biliary anatomy. Routine intra-operative cholangiography has been recommended to reduce accidental duct injury, although in practice it is more often reserved for selected cases. There has been interest in the use of fluorescent agents excreted via the biliary system to enable real-time intra-operative imaging, to aid the laparoscopic surgeon in correctly interpreting the anatomy. The primary aim of this review is to evaluate the ability of fluorescent cholangiography to identify important biliary anatomy intra-operatively. Secondary aims are to investigate its ability to detect important intra-operative pathology such as bile leaks, identify potential alternative fluorophores, and evaluate the evidence regarding patient outcomes.