Intraoperative visualization of biliary anatomy using Indocyanine green (ICG) fluorescence in a Sri Lankan patient cohort

Abstract

INTRODUCTION: Bile duct injury (BDI) is a complication with high morbidity, associated with laparoscopic cholecystectomy (LC). The risk of BDI can be reduced by accurate visualization of the biliary tree with the use of indocyanine green fluorescence (ICG). This study describes the use of this non-invasive technique in a cohort of Sri Lankan patients to visualize the biliary anatomy intraoperatively. METHOD: A total of 121 consecutive patients undergoing LC were included. All received 5 mg of ICG intravenously, 30 minutes prior to induction of anesthesia. The Stryker 1588 laparoscope was used to visualize the anatomical landmarks, both pre and post-dissection of the Calot's triangle, using visible light and near-infrared imaging (NIR). RESULT: In 121 patients (female - 64.5%, median age - 42 years; range of 18-82) included in the study, biliary colic was the commonest indication (70%) for LC. ICG fluorescence resulted in significantly better visualization of the extrahepatic biliary tract (p=<0.001), both pre-dissection (95%CI = 91.7% [85.3%-96.0%]) and post-dissection (95% CI=71.1% [62.1%-79.0%]) of the Calot's triangle. Furthermore, the hepatic ducts were only visualized with ICG. Visualization of the Cystic duct common bile duct junction (CDCBDJ) improved from 6% to 88% (P<0.001) predissection with ICG. Fluorescence enabled the visualization of CDCBDJ post-dissection in all cases compared to 54% without it (P<0.001). ICG enhanced visualization of the Common bile duct (CBD) from 34% to 88% (P<0.001) predissection and 100% visibility post-dissection compared to 62% under visible light (P<0.001). No adverse effects of ICG or bile duct injuries were reported during the study. CONCLUSION: The use of ICG during LC significantly enhanced the identification of biliary landmarks in this cohort. Identification of anatomy can help reduce inadvertent BDI. This safe and effective modality may be considered a routine step in LC.