Indocyanine green enhanced imaging during three instrument cholecystectomy using a modified dome down technique

Hugo Bonatti, MD, Aboubakr Khairat, MD, Andrew Pelczar. University of Maryland Shore Health

Objective: Fluorescence imaging with indocyanin green (ICG) has been used to determine perfusion of tissue. The agent is excreted through the liver and the biliary tree can be visualized during laparoscopic cholecystectomy.

Methods: During two trial phases (8-9/2014 and 7-10/2015), a total of 22 laparoscopic cholcystectomies with ICG imaging were performed using a 3 instrument and modified dome down technique. ICG was given iv 15-45 minutes prior to incision at a dose of 0.25-0.75ml. A five mm port is placed in the left upper quadrant, a 10-12 mm trocar into the umbilicus and another 5mm trocar or a mingrasper between the two trocars. The gallbladder-serosa is incised on both sides and the plane between gallbladder and liver tissue is determined using laser excitement. A window behind the midportion of the gallbladder is created and widened towards fundus and infundibulum. The critical view is obtained and cystic artery and duct are secured with clips or endoloop.

Results: Median age of seven men and 15 women was 69 (range 29.1-80.7) years. Indications for LC were acute cholecystitis (n=9), chronic cholecystitis (n=9), biliary dyskinesia (n=1), st/p biliary pancreatitis (n=2), st/p stone passage (n=1). In all except one cases, the procedure could be completed with three instruments, the minigrasper was used in 15 cases. In 41% additional procedures were performed with lysis of adhesions being the most commen (n=7). Dissection was done in 27% with classic dome down and in 73% using a modified dome down technique. In all cases cystic artery and hepatic/common bile duct were visualized before dividing any structure. Closure of the cystic artery was done with clips in 19 cases, in four cases the artery was small and was divided with electrocautery; cystic duct closure was done with clips in 13 and with an endoloop in nine patients. There were no vascular or bile duct injuries in this series. One patient had a leak from the cystic duct (which was found partially necrotic during surgery) and was successfully treated with ERCP and stenting. 13% cases were done as outpatient procedures, 53% required 23hours observation and 33% of patients were hospitalized.

Conclusions: This case series demonstrates feasibility of this technique variation. ICG fluorescence imaging was found useful for visualization of cystic and common bile duct and to determine the tissue plane between liver and gallbladder. Adaption of port/minigrasper placement allows for completion with three instruments in 95%.