Accuracy of Near Infrared Guided Surgery in Morbidly Obese Subjects Undergoing Laparoscopic Cholecystectomy

Fernando Dip, MD, David Nguyen, MD, Lisandro Montorfano, MD, Maria Eugenia Szretter, MSc, Emanuele Lo Menzo, MD, PhD, FACS, Samuel Szomstein, MD, FACS, Raul Rosenthal, MD, FACS. Cleveland Clinic Florida


Methods and techniques of intraoperative cholangiogram and critical view of safety have been implemented to reduce biliary injuries. However, the incidence of biliary injuries has remained at 0.4% in the last two decades. Recently, a novel method is gaining appreciation in minimizing this adverse event. Fluorescence image guided surgery in laparoscopic cholecystectomy represents an incisionless technique that can be applied multiple times during surgery. However, tissue thickness may present limitations in this evolving method. Our objective was to evaluate and detect variances of fluorescence imaging in obese and non-obese patients undergoing laparoscopic cholecystectomies.

Study Design

Prospective patients undergoing laparoscopic cholecystectomies participated in the study. Subjects were classify based on their body mass index of ≥ 30 and <30. Diagnoses of cholelithiasis, acute, and chronic cholecystitis were determined. Fluorescence imaging was applied preceding any dissection of extrahepatic ducts and again after dissection. Positive and negative identifications of biliary ducts prior to any transections were recorded. Intraoperative cholangiogram and critical view of safety were performed in all cases.


Seventy-one patients participated with 53.5% classified as obese. The cystic, hepatic, common, and accessory ducts were identified as follow: 100%, 70.4%, 87.3%, and 7.0% of patients respectively. No differences in hepatic duct, common bile duct, and accessory duct visualization were detected in the obese and non-obese groups, p-value 0.09, 0.23, and 0.87 respectively Visualization of the hepatic duct decreased significantly from tissue inflammation in obese patients, p-value 0.04.


Fluorescent cholangiography is a useful technique to perform in obese and non-obese patients. Although obesity has no impact on fluorescence visualization of bile ducts, obesity was shown to be an influencing factor in decreased fluorescent light penetration. This was due to inflammation of excess extrahepatic tissue.

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