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

•

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

•

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

•

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.