Does Indocyanine Green Cholangiography Identify Critical View of Safety Earlier in Laparoscopic Cholecystectomy ? Results from a Randomised Control Study in University Malaya Medical Centre

Abstract

Introduction: Indocyanine green (ICG) cholangiography helps identify biliary structures during laparoscopic cholecystectomy (LC). Our study aims to determine if ICG cholangiography assisted LC (ICG –LC) could reach critical view of safety (CVS) earlier compared to conventional white light LC. Method: Patients were randomly grouped into ICG-LC and LC. ICG was administered intravenously to patients preoperatively in the ICG-LC group. Laparoscopic fluorescence imaging system was used during dissection of Calot’s triangle in this group. Duration of time from gallbladder retraction until identification of CVS for each group was measured. All surgeries were performed by the same surgeon and the intraoperative difficulty was rated arbitrarily from level 1 being least difficult to level 4 being most difficult. The data was compared and analysed. Result: Fifty two patients were randomised, 24 patients in ICG-LC and 28 in LC group. There was no significant difference in the median time to identification of CVS in the overall analysis, which was 22 minutes in ICG-LC group and 18 minutes in LC group (p value 0.556). In the subgroup analysis, both ICG-LC and LC group recorded a median time of 13 minutes to reach CVS in level 1 difficulty cholecystectomy, while level 2 was 21 minutes in the ICG- LC group compared to 17 minutes in the LC group (p value 0.662). In level 3, ICG-LC took 41 minutes compared to 38 minutes in LC (p value 0.346). Median time for ICG-LC was faster for Level 4 where it took 48 minutes compared to 54.5 minutes in LC (p value 0.221). No major adverse events were recorded. Conclusion: Use of ICG does not shorten duration of CVS identification. The longer duration taken with ICG could be attributed to more careful dissection from aided visualised anatomy. ICG may be useful to identify CVS earlier for difficult gallbladders but further study is needed.