Laparoscopic Fluorescence Cholangiography: What and when?

Laparoscopic cholecystectomy is one of the most frequently performed laparoscopic operations. For a safe procedure, the Society of American Gastrointestinal and Endoscopic Surgeons strongly advises to use “the critical view of safety” as a strategy to minimize bile duct injuries. The “critical view of safety” is based on the identification of the hepatocystic triangle, which is defined as the triangle formed by the cystic duct, the common hepatic duct, and the inferior edge of the liver.

The “critical view of safety” and recognition of the anatomical structures can be difficult in patients with cholecystitis, or due to fibrotic tissue or adhesions in patients who have had a cholecystitis, pancreatitis or previous upper abdominal surgery, thereby leading to misidentification of the common bile duct or the common hepatic duct for the cystic duct. A Swedish gallstone surgery registry reported complication rates of 6.1% in patients after elective cholecystectomy and almost double in patients after emergency cholecystectomy. In case of a bile duct injury, its extent leads in the choice of treatment. This can vary from prolonged use of an intra-abdominal drain to an emergency hepaticojejunostomy.

To identify the bile ducts during cholecystectomy, an intraoperative cholangiography can be performed. But among other risks, this is time-consuming and exposes the patient and healthcare providers to radiation. An alternative to the intraoperative cholangiography is near-infrared (NIR) fluorescence cholangiography using indocyanine green (ICG). This seems to be a useful, safe, and cost-effective tool to identify the bile ducts during cholecystectomy. In this talk, we will focus on the details of bile duct injuries after laparoscopic cholecystectomy and the role of fluorescence cholangiography.