Routine Use of Intraoperative Fluorescent Cholangiography During Robotic Cholecystectomy Minimizes Risk of Common Bile Duct Injury and Decreases Operative Time

Thomas J Shaknovsky, DO, Frederick Sabido, MD, FACS. Richmond University Medical Center, Affiliate of Downstate Medical Center, Department of Minimally Invasive Surgery

INTRODUCTION: Since March 2014 our group has adopted robotic single site cholecystectomy utilizing 3DHD endoscope with routine intra-operative fluorescent cholangiography (Firefly). At this point we have performed over 135 cases with excellent results. We have had no major complications to date, including zero common bile duct (CBD) injuries. 

OBJECTIVE: Recently, SAGES introduced the Safe Cholecystectomy Initiative and recommended “liberal use of cholangiography or other methods to image the biliary tree intraoperatively”. Our institution participated in a multicenter nationwide pilot program comparing traditional laparoscopic visualization to the robotic platform 3DHD endoscope with Firefly imaging. The goal of the pilot was to answer: can this advanced technology improve anatomical visualization and does combination of Firefly with 3DHD endoscope have a role in surgical practice?

DESCRIPTION: The injectable fluorescent dye Indocyanine Green (ICG) is administered through peripheral IV and binds to plasma proteins in the blood. Approximately 45 minutes later the ICG complex reaches the biliary circulation. Next, the 3DHD endoscope fluorescent enabled hardware provides an infrared excitation laser (805 nm) causing ICG complex to emit an infrared signal (830 nm). Fluorescing ICG signal is transmitted to the computer core and provides the surgeon with real-time image guided visualization of key anatomical landmarks.

METHODS: Over 4 month period a multi – institutional prospective study was conducted encompassing 210 patients. Twenty general surgeons participated including two from our institution. Laparoscopic cholecystecomy with cholangiogram, laparoscopic cholecystectomy without cholangiogram, robotic cholecystectomy with Firefly imaging and robotic cholecystecomy without Firefly imaging were tracked and analyzed. Participating surgeons logged information regarding cholecystectomies performed in real time. Total skin-skin time, case difficulty, visualization of Triangle of Calot, control during dissection and overall procedure satisfaction were tracked. Surgeon’s evaluation of each category as it pertained to the cholecystectomy performed was recorded on a 1 to 5 scale. Numerical values of 1 correlated to unsatisfied/most difficult and numerical value of 5 correlated to extremely satisfied/easiest. Using statistical analysis computed derived value for each recorded category was obtained.


In general, robotic groups provided surgeons with higher anatomical visualization in comparison to laparoscopy groups. Specifically, the use of Firefly resulted in superior Triangle of Calot visualization (4.4/5) thus correlating to the highest overall surgeon satisfaction score (4.6/5). Surgical cases in the robotic cholecystectomy with Firefly arm were perceived as the most difficult (2.9/5) of all four groups. Robotic cholecystectomy with Firefly group demonstrated the highest degree of intra-operative control of dissection (4.6/5). Laparoscopic cholecystectomy without cholangiogram group had the shortest mean operative time (54.7 minutes) and robotic cholecystectomy without Firefly had the longest (64 minutes). Addition of Firefly imaging during robotic cholecystectomy resulted in decrease of operative time by 9.3 minutes.

CONCLUSION: Study outcomes reaffirm our initial experience: robotic platform’s 3DHD endoscope imaging coupled with routine use of intra-operative fluorescence cholangiography (Firefly) is the safest approach to cholecystectomy. Fluorescent imaging affords superior anatomical visualization compared to the naked eye thus enhancing surgeon's vision, precisions and control. Improved visualization minimizes the risk of CBD injury and decreases overall operative time.

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