Combined Near-infrared Fluorescence Laparoscopy of the Extra-hepatic Bile Ducts and Arterial anatomy: Results of a Feasibility Study

R.m. Schols, MD, N.d. Bouvy, MD, PhD, A.a.m. Masclee, MD, PhD, R.m. van Dam, MD, C.h.c. Dejong, MD, PhD, L.p.s. Stassen, MD, PhD

Departments of Surgery and Gastroenterology, Maastricht University Medical Center, The Netherlands

INTRODUCTION: Laparoscopic cholecystectomy (LC) is one of the most commonly performed laparoscopic procedures. Bile duct injury (BDI) is a rare, but serious complication during this procedure, mostly caused by misidentification of the extra-hepatic bile duct anatomy. Intraoperative cholangiography may be helpful to reduce the risk of BDI; however this is not a common procedure worldwide. Near-infrared fluorescence (NIRF) imaging using indocyanin green (ICG) is a promising alternative for the identification of the biliary anatomy.
Aim: to assess the feasibility and potential of intermittent NIRF during LC, using a newly developed laparoscopic fluorescence imaging system, for early biliary tract delineation.

METHODS AND PROCEDURES: Patients undergoing elective LC were included and received one intravenous injection of ICG directly after induction of anesthesia and a repeat intravenous injection at establishment of Critical View of Safety (CVS). During dissection of the base of the gallbladder and the cystic duct the extra-hepatic bile ducts were visualized using a dedicated laparoscope, which offers both conventional state-of-the-art imaging and fluorescence imaging. Intraoperative recognition of the biliary structures was registered at set time points, as well as the arterial anatomy confirmation at establishment of CVS.

RESULTS: 30 patients were included. ICG was visible in the liver and bile ducts within 20 minutes after intravenous administration and remained so up to approximately 2 hours, using the fluorescence mode of the laparoscope. The common bile duct and cystic duct could be clearly identified at an early stage of the operation and more important, significantly earlier than with the conventional camera mode. Confirmation of the cystic artery was successfully obtained after repeat intravenous ICG injection at establishment of CVS. No prolonged preparation time before start of surgery and only a negligible extension of the operation time (<2 minutes) was observed, due to the use of the NIRF technique. No per- or postoperative complications occurred as a consequence of ICG use.

CONCLUSION: Intermittent fluorescence imaging using a newly developed laparoscope, after administration of ICG, seems a useful aid in accelerating visualization of the extra-hepatic bile ducts and for confirmation of the arterial anatomy during laparoscopic cholecystectomy. Thereby it most likely increases safety of the procedure.

Session: Podium Presentation

Program Number: S005

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