Intraoperative near-infrared fluorescent cholangiography during Single Site Robotic Cholecystectomy

Fabio Priora, MD, Luca Matteo Lenti, PhD, Ferruccio Ravazzoni, PhD, Alessandra Marano, MD, Giulio Argenio, MD, Giuseppe Spinoglio, MD

Surgical Department – Unito of General and Oncologic Surgery – Ss. Antonio e Biagio Hospital

OBJECTIVE The application of the fluorescence with indocyanine green (IG) in robotic surgery is a recent challenging technique. Thanks to its favourable characteristics, this contrast agent can be easily injected (bolus) into the blood circulation during the surgery allowing a direct visualization of vascular anatomy of the organs and their perfusion. Moreover, since ICG has an exclusive biliary excretion, the intraoperative IG near-infrared (NIR) fluorescent cholangiography may facilitate better understanding of hepatobiliary anatomy. On all these principles is based the recent introduction of a NIR fluorescent system integrated into da Vinci Si HD System (Intuitive Surgical, Sunnyvale, CA).

DESCRIPTION The new robotic fluorescent system includes a surgical endoscope capable of visible light and NIR imaging, a 3DHD stereoscopic camera head that couples to the endoscope and an endoscopic illuminator that provides visible light and NIR illumination through the surgical endoscope via a flexible light guide. The surgeon can quickly switch between normal viewing mode (visible light) to fluorescence (NIR) by pressing the pedal of the surgical console, always viewing in high definition mode.

PRELIMINARY RESULTS From July 2011 to January 2012 a total of forty-five consecutive patients affected by pure symptomatic cholelithiasis underwent single site robotic cholecystectomy (SSRC) with ICG-NIR fluorescent cholangiography using the da Vinci Fluorescence Imaging Vision System. A dose of 2.5 mg of ICG was intravenously administered about 30-45 minutes before the surgery; if the fluorescence was not detected in the liver 60 minutes after the injection of the first dose, an extra dose of 2.5 mg was administered again. Once Calot’s triangle was visualized, the fluorescence imaging mode was selected from the robotic camera view in order to identify the anatomy of the extra hepaticbiliary tree. As Calot’s dissection proceeds, when cystic duct and artery were ready to be resected, a second evaluation of the biliary anatomy was performed by switching again to fluorescence imaging modality. The rates of visualizations for cystic duct (CD), common hepatic duct (CHD) and common bile duct (CBD) were 93%, 88% and 91% before Calot’s dissection and 97%, 97% and 97% after Calot’s dissection, respectively. At least one duct was visualized in all patients (100%) prior to Calot’s dissection. Any conversion to open or laparoscopy occurred; any additional ports have been placed and a second additional dose of ICG was never required. There were no bile duct injuries or other major complications. The mean hospital stay was 1.1 days and 92% patients were discharged within 24 hours after the surgery. There were no complications until 30days follow-up.

CONCLUSIONS Our initial experience is the first prospective study described up to date in literature and confirms the benefits and the encouraging shortcomings of the robotic surgery combined with the fluorescence system. SSRC using ICG NIR fluorescent cholangiography has been shown to be effective and safe to detect the extra biliary anatomy without increasing the morbidity in addition to improve the safety of a single incision surgery. Currently, prospective multicenter studies evaluating the impact of the fluorescence in other surgical fields are in progress.

Session: Podium Presentation

Program Number: ET006