Techniques of Fluorescence Cholangiography During Laparoscopic Cholecystectomy for Better Delineation of the Bile Duct Anatomy

Abstract To evaluate the clinical and technical factors affecting the ability of fluorescence cholangiography (FC) using indocyanine green (ICG) to delineate the bile duct anatomy during laparoscopic cholecystectomy (LC). Application of FC during LC began after laparoscopic fluorescence imaging systems became commercially available. In 108 patients undergoing LC, FC was performed by preoperative intravenous injection of ICG (2.5 mg) during dissection of Calot's triangle, and clinical factors affecting the ability of FC to delineate the extrahepatic bile ducts were evaluated. Equipment-related factors associated with bile duct detectability were also assessed among 5 laparoscopic systems and 1 open fluorescence imaging system in ex vivo studies. FC delineated the confluence between the cystic duct and common hepatic duct (CyD–CHD) before and after dissection of Calot's triangle in 80 patients (74%) and 99 patients (92%), respectively. The interval between ICG injection and FC before dissection of Calot's triangle was significantly longer in the 80 patients in whom the CyD–CHD confluence was detected by fluorescence imaging before dissection (median, 90 min; range, 15–165 min) than in the remaining 28 patients in whom the confluence was undetectable (median, 47 min; range, 21–205 min; P < 0.01). The signal contrast on the fluorescence images of the bile duct samples was significantly different among the laparoscopic imaging systems and tended to decrease more steeply than those of the open imaging system as the target-laparoscope distance increased and porcine tissues covering the samples became thicker. FC is a simple navigation tool for obtaining a biliary roadmap to reach the “critical view of safety” during LC. Key factors for better bile duct identification by FC are administration of ICG as far in advance as possible before surgery, sufficient extension of connective tissues around the bile ducts, and placement of the tip of laparoscope close and vertically to Calot's triangle.

[1]  R. Rosenthal,et al.  Routine use of fluorescent incisionless cholangiography as a new imaging modality during laparoscopic cholecystectomy , 2015, Surgical Endoscopy.

[2]  D. Gouma,et al.  Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines , 2007, Journal of hepato-biliary-pancreatic surgery.

[3]  N. Sacharias,et al.  Preoperative screening for common bile duct stones with infusion cholangiography: review of 1000 patients. , 1997, Annals of surgery.

[4]  P. Ebert,et al.  Anomalies of the biliary tree. Report of a repair of an accessory bile duct and review of the literature. , 1972, Archives of surgery.

[5]  Vimal K. Narula,et al.  Near-infrared fluorescent cholangiography facilitates identification of biliary anatomy during laparoscopic cholecystectomy , 2015, Surgical Endoscopy.

[6]  Giuseppe Spinoglio,et al.  Real-time near-infrared (NIR) fluorescent cholangiography in single-site robotic cholecystectomy (SSRC): a single-institutional prospective study , 2013, Surgical Endoscopy.

[7]  K. Hasegawa,et al.  Fluorescent cholangiography illuminating the biliary tree during laparoscopic cholecystectomy , 2010, The British journal of surgery.

[8]  R. Page,et al.  A practical reappraisal of the anatomy of the extrahepatic bile ducts and arteries , 1976, The British journal of surgery.

[9]  Rutger M. Schols,et al.  Combined vascular and biliary fluorescence imaging in laparoscopic cholecystectomy , 2013, Surgical Endoscopy.

[10]  M W Knuiman,et al.  Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population-based study. , 1999, Annals of surgery.

[11]  Ronan A. Cahill,et al.  Near-infrared (NIR) laparoscopy for intraoperative lymphatic road-mapping and sentinel node identification during definitive surgical resection of early-stage colorectal neoplasia , 2011, Surgical Endoscopy.

[12]  T. Koepsell,et al.  Intraoperative cholangiography and risk of common bile duct injury during cholecystectomy. , 2003, JAMA.

[13]  J. Hunter,et al.  Biliary tract complications of laparoscopic cholecystectomy are detected more frequently with routine intraoperative cholangiography , 1995, Surgical Endoscopy.

[14]  Brice Gayet,et al.  Positive and negative staining of hepatic segments by use of fluorescent imaging techniques during laparoscopic hepatectomy. , 2012, Archives of surgery.

[15]  D. Sherwinter Identification of Anomolous Biliary Anatomy Using Near-Infrared Cholangiography , 2012, Journal of Gastrointestinal Surgery.

[16]  B. Anson,et al.  Variations in the formation and vascular relationships of the bile ducts. , 1952, Surgery, gynecology & obstetrics.

[17]  Luc Soler,et al.  Real-time navigation by fluorescence-based enhanced reality for precise estimation of future anastomotic site in digestive surgery , 2014, Surgical Endoscopy.

[18]  L. Way,et al.  Causes and Prevention of Laparoscopic Bile Duct Injuries: Analysis of 252 Cases From a Human Factors and Cognitive Psychology Perspective , 2003, Annals of surgery.

[19]  J. Goodwin,et al.  Variation in the use of intraoperative cholangiography during cholecystectomy. , 2012, Journal of the American College of Surgeons.

[20]  S. White,et al.  Intraoperative cholangiography in the laparoscopic cholecystectomy era: why are we still debating? , 2012, Surgical Endoscopy.

[21]  L Morgenstern,et al.  An analysis of the problem of biliary injury during laparoscopic cholecystectomy. , 1995, Journal of the American College of Surgeons.

[22]  G. Kwant,et al.  Light-absorbing properties, stability, and spectral stabilization of indocyanine green. , 1976, Journal of applied physiology.

[23]  B. Sigel,et al.  Laparoscopic ultrasonography versus operative cholangiography during laparoscopic cholecystectomy: review of the literature and a comparison with open intraoperative ultrasonography. , 1999, Journal of the American College of Surgeons.

[24]  A. Vahrmeijer,et al.  Optimization of near-infrared fluorescence cholangiography for open and laparoscopic surgery , 2014, Surgical Endoscopy.

[25]  Yoshihiro Sakamoto,et al.  Visualization of subcapsular hepatic malignancy by indocyanine-green fluorescence imaging during laparoscopic hepatectomy , 2014, Surgical Endoscopy.

[26]  E. Phillips,et al.  Routine cholangiography reduces sequelae of common bile duct injuries , 1996, Surgical Endoscopy.

[27]  C. S. Davidson,et al.  Indocyanine green: observations on its physical properties, plasma decay, and hepatic extraction. , 1960, The Journal of clinical investigation.

[28]  Mitsugi Shimoda,et al.  Intraoperative exploration of biliary anatomy using fluorescence imaging of indocyanine green in experimental and clinical cholecystectomies , 2010, Journal of hepato-biliary-pancreatic sciences.

[29]  Hiroshi Imamura,et al.  Intraoperative fluorescent cholangiography using indocyanine green: a biliary road map for safe surgery. , 2009, Journal of the American College of Surgeons.