Direct Gallbladder Indocyanine Green Injection Fluorescence Cholangiography During Laparoscopic Cholecystectomy

Abstract

Background: Currently, intravenous injection of indocyanine green (ICG) is used to illuminate extrahepatic biliary anatomy.1–9 Fluorescence of biliary structures may lower surgical complications that can arise because of inadvertent injury to the common bile duct. In this video, we describe a method of injecting ICG directly into the gallbladder to define the cystic duct and common bile duct anatomy.10 Materials and Methods: A standard laparoscopic cholecystectomy was performed on 11 patients (7 males and 4 females, average age 16 years) using a laparoscope with near-infrared imaging capability. Before dissection, the gallbladder was punctured with a cholangiogram catheter or a pigtail catheter to aspirate the bile within the gallbladder. The aspirated bile is mixed with ICG solution, which is reinjected into the gallbladder to immediately fluoresce the gallbladder, cystic duct, and common bile duct structures. Results and Conclusions: All 11 patients underwent direct gallbladder ICG injection for fluorescence cholangiography during cholecystectomy. Direct gallbladder ICG injection clearly defined the extrahepatic biliary anatomy, including the cystic duct–common bile duct junction, by fluorescence. In addition, direct gallbladder ICG fluorescence highlights the dissection plane between the gallbladder and the liver, allowing for a more efficient dissection and early identification of accessory bile ducts arising from the gallbladder fossa, a benefit that is impossible with the background liver fluorescence seen with intravenous ICG injection. In conclusion, direct gallbladder ICG injection provides immediate observation of extrahepatic biliary structures and clarifies the dissection plane between the gallbladder and the liver bed. No competing financial interests exist. Runtime of video: 5 mins 36 secs Presented at the American Pediatric Surgical Association Annual meeting, Hollywood, FL, May 3–7, 2017.