Laparoscopic Cholecystectomy Using Intraoperative Fluorescent Cholangiography

OBJECTIVE: Although intraoperative cholangiography (IOC) has been recommended for avoiding bile duct injury during laparoscopic cholecystectomy (LC), radiographic IOC is time-consuming and the procedure itself may cause bile duct injury. We have developed a novel fluorescent cholangiography technique by applying the principle that indocyanine green (ICG) is excreted into bile and emits light with a peak wavelength of around 830 nm when illuminated with near-infrared light. The aim of this study was to evaluate the ability of fluorescent cholangiography to detect the bile duct anatomy during LC, especially in patients with accessory bile ducts.
METHODS: In 43 patients undergoing laparoscopic cholecystectomy, ICG (2.5 mg) was intravenously injected before surgery. A fluorescent imaging system (prototype; Hamamatsu Photonics Co., Hamamatsu, Japan) comprised of a xenon light source and a laparoscope with a charge-coupled device camera, which can filter out light wavelengths below 810 nm, was utilized. Fluorescent cholangiography was performed before and during the dissection of the triangle of Calot by changing from color images to fluorescent images using a foot switch. The ability of fluorescent cholangiography to detect the bile duct anatomy was evaluated by comparing the fluorescent images with preoperative cholangiography findings.
RESULTS: Fluorescent cholangiography delineated the cystic duct in all 43 patients and the cystic duct – common hepatic duct (CHD) junction in 41 patients prior to the dissection of the triangle of Calot (FIGURE). This technique also identified all the accessory bile ducts that were preoperatively diagnosed in 7 patients. We will present videos demonstrating the dissection of the triangle of Calot using fluorescent cholangiography in a patient with the normal bile duct anatomy and another two patients with an accessory hepatic duct draining the right lateral sector or the left paramedian sector of the liver and directly entering the CHD. No adverse reactions to the ICG or postoperative bile leaks were encountered.
CONCLUSIONS: Fluorescent cholangiography enables real-time identification of accessory hepatic ducts as well as the cystic duct and the common hepatic duct during the dissection of the triangle of Calot. This safe and simple technique has the potential to become a standard practice for avoiding bile duct injury during LC, replacing conventional radiographic IOC.

FIGURE
Fluorescent cholangiography (A) before the dissection of the triangle of Calot clearly delineates the bile duct anatomy, which are unidentifiable on color images (B). Arrow shows the cystic duct – CHD junction.

Session: Podium Video Presentation

Program Number: V003