Near Infrared Fluorescent Cholangiography Facilitates Identification of Biliary Anatomy During Laparoscopic Cholecystectomy

Sylvester N Osayi, MD, Mark R Wendling, MD, Umer I Chaudhry, MD, Joseph M Drosdeck, MD, Kyle A Perry, MD, Sabrena F Noria, MD, Jeffrey W Hazey, MD, Peter Muscarella, MD, W. Scott Melvin, MD, Vimal K Narula, MD. The Ohio State University Wexner Medical Center, Columbus, OH, USA 43210.

INTRODUCTION: Bile duct injury remains the most feared complication of laparoscopic cholecystectomy. Intraoperative cholangiography (IOC) is the current gold standard for biliary imaging and may reduce injury, but is not widely used. Near Infrared Fluorescence Cholangiography (NIRF-C) is a novel non-invasive method for real-time, radiation free, intra-operative biliary mapping. We hypothesized that NIRF-C is a safe and effective method for identifying biliary anatomy during laparoscopic cholecystectomy.

METHODS AND PROCEDURES: After obtaining informed consent, we administered 2.5 mg of indocyanine green (ICG) intravenously approximately 60 minutes prior to incision. NIRF-C was used to identify extrahepatic biliary structures at 3 time points: at initial entrance into the peritoneal cavity, partial dissection, and complete dissection of Calot’s triangle. IOC was performed after complete dissection. Identification of the following structures was recorded: right and left hepatic ducts, common hepatic duct (CHD), common hepatic/cystic duct (CH/CD) junction, cystic duct (CD), common bile duct (CBD), cystic artery, and anatomic variants. Time required to complete NIRF-C and IOC, length of procedure, complications, and procedure cost were collected. A student t-test was used for data analysis with significance when P<0.05.

RESULTS: Fifty-three patients underwent elective laparoscopic cholecystectomy with NIRF-C and IOC. Patients were 81.3% female with a mean age of 41.7 (range 18-77) and mean BMI of 30.9 (range 17.7-48.8). ICG was administered 78.7 mins (range 29-162) prior to incision. Mean operative time was 72.4 mins (range 33-225). There was a statistically significant difference between the average time spent on NIRF-C at 2.4 min (range 0.18-10.58) vs. 11.0 min (range 4.5-26.8) for IOC (p<0.001). NIRF-C did not visualize any structure in 2 (3.8%) patients due to bile leak and chronic cholecystitis, while IOC was unable to be performed in 11 (20.8%) patients either due to technical difficulties or unavailable equipment. After complete dissection of Calot’s triangle, visualization with NIRF-C of the CHD was achieved 73.6% of the time, CBD 77.4%, and CD 96.2%, compared to IOC CHD 79.3%, CBD 79.3% and CD 75.5%. There was a statistically significant difference between NIRF-C and IOC visualization of the CD (p=0.002). Also, the CD was visualized with NIRF-C in 10 (90.9%) of the cases where IOC was unable to be performed. There were no intra-operative complications. The cost of ICG for NIRF-C was $99/patient, significantly less than the additional hospital charge of $2755/patient for an IOC.

CONCLUSIONS: NIRF-C is a safe and effective alternative to IOC for imaging extrahepatic biliary structures during laparoscopic cholecystectomy. Significantly less time was required to perform NIRF-C than IOC and it is significantly cheaper to use compared to IOC. NIRF-C has the potential to decrease bile duct injury at a significantly lower cost than the use of routine IOC during laparoscopic cholecystectomy.

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