Use of Indocyanine Green augmented Near Infrared Fluorescence Imaging in identification of biliary anatomy during Robotic Radical Resection of Gallbladder Adenocarcinomas.

Ali Ahmad, MD, FACS. University of Kansas School of Medicine-Wichita

Introduction: Gallbladder cancer remains a rare cancer with a poor prognosis. National guidelines recommend radical resection in the absence of metastatic disease. This often requires extensive dissection around the extrahepatic bile ducts. We report our experience of real-time near-infrared fluorescence (NIRF) imaging using indocyanine green (ICG) during robotic radical resection of gallbladder adenocarcinomas.

Methods: Six patients with gallbladder adenocarcinoma underwent robotic radical resection entailing central hepatectomy (segments IV-B and V) with regional lymphadenectomy. Real time NIRF imaging was performed using the da Vinci® Firefly system after administration of 5mg of ICG 30 to 60 minutes preoperatively. Primary objective was to determine safety of this technique.

Results: Procedure was successfully completed in all patients. Four patients had incidentally discovered gallbladder cancer after laparoscopic cholecystectomy and had preoperatively known positive margins. Mean operative time was 220 minutes. Mean intraoperative blood loss was 50mL (30-250mL). Median number of lymph nodes retrieved was 5 (4-7). High ligation of cystic duct was performed close to the common bile duct (CBD) junction with the assist of NIRF and negative margins were achieved in all patients. No procedural complications or mortality was seen at 30 days post-op.

Conclusion: Results from our limited experience demonstrate procedural safety and beneficial use of NIFC using ICG during robotic radical resection of gallbladder adenocarcinomas. It may assist in attainment of negative cystic duct margin and lymphatic clearance around the biliary tree especially in complex re-explorative biliary surgery.

**Table 1**
Patient	Age (Yrs)	Sex	Lymph nodes (Positive/Total)	Final Pathology	Negative Margins
1	69	F	2/5	T2N1	Yes
2	84	M	5/6	T3N2	Yes
3	74	F	0/5	T2N0	Yes
4	60	F	3/7	T3N2	Yes
5	67	F	1/4	T3N1	Yes
6	71	M	0/6	T2N0	Yes