Priti Lalchandani, MD, Jennifer A Smith, MD, Beverley A Petrie, MD. Harbor-UCLA Medical Center
INTRODUCTION: The inability to identify biliary anatomy has been identified as the cause of bile duct injury (BDI) in 71-97% of laparoscopic cholecystectomies. Indocynanine green (ICG) has emerged as a safe and effective modality to visualize biliary anatomy. Near-infrared laser beams excite ICG causing emission of light and resultant imaging of the biliary tree. ICG is given prior to robotic near-infrared fluorescence cholangiography (NIFC) visualization of the biliary ducts. In this report, we compared the extrahepatic and intrahepatic biliary anatomy of a patient utilizing both laparoscopic intraoperative cholangiography (IOC) and robotic NIFC.
METHOD/PROCEDURE: A 28-year-old presented with 5-years of post-prandial right upper quadrant pain and was found to have cholelithiasis and normal common bile duct on ultrasound. Robotic NIFC performed for academic purposes detected an aberrant cystic duct. Given the finding of a double cystic duct, the case was converted to a laparoscopic approach in order to perform a comparative evaluation of the biliary anatomy utilizimg IOC.
RESULTS: Laparoscopic IOC did not reveal the aberrant double cystic duct seen on robotic NIFC (Figure 1, 2). However, an incidental anomalous intrahepatic right posterior hepatic duct was noted on laparoscopic IOC (Figure 3). Interestingly, this intrahepatic abnormality was not seen on robotic NIFC. Ultimately the cholecystectomy was completed without BDI.
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FIGURE 1. Robotic near-infrared fluorescence cholangiography.
A Gallbladder infundibulum. | B Anterior aberrant double cystic duct. | C Cystic duct. | D Common hepatic duct. | E Common bile duct. | F Liver.
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FIGURE 2. Robotic image of gallbladder with double cystic duct.
A Gallbladder body. | B Aberrant anterior double cystic duct (clipped and transected). | C Cystic duct.
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FIGURE 3. Laparoscopic intraoperative cholangiography.
A Right anterior hepatic duct. | B Left hepatic duct. | C Common hepatic duct. | D Cystic duct. | E Common bile duct. | F Duodenum. | G Contrast extravasation. | H Right posterior hepatic duct.
CONCLUSION: Laparoscopic IOC has been well studied and has been shown to accurately detect extrahepatic and intrahepatic biliary anatomy. In recent studies, robotic NIFC has been reported to reveal extrahepatic biliary anatomy with noteworthy accuracy. Remarkably, robotic NIFC may actually outperform laparoscopic IOC in detection of extrahepatic biliary anatomy due to its four times standard view of the ICG image. Therefore, NIFC performed during robotic cholecystectomy is an effective procedure that helps real-time visualization of the extrahepatic biliary anatomy. Yet its ability to elucidate intrahepatic biliary anatomy and whether that information has a salient affect on minimally invasive cholecystectomy outcomes remain unclear.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95974
Program Number: P705
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster