Fluorescent cholangiography during laparoscopic cholecystectomy by intracholecystic administration of indocyanine green

Abstract

Introduction: Pitfall of indocyanine green (ICG) fluorescent cholangiography application in acute calcalous cholecystitis initially treated with percutaneous transhepatic gallbladder drainage (PTGBD). Methods: Ultrasonically guided PTGBD procedure was developed in urgent setting in two patients age older than 70-year-old with moderate acute calcalous cholecystitis based on diagnostic criteria of the Tokyo guidelines. Our patients then received interval laparoscopic cholecystectomy 2 weeks after drainage procedure. We applied two kinds of the route of ICG injection for fluorescent intraoperative cholangiography: intrabiliary and intravenous injections. ICG 5 ml (0.025 mg/mL; Diagnogreen; Daiichi Sankyo Co, Tokyo, Japan) was administered into the bile duct through the PTGBD tube. The cystobiliary junction was clearly visualized by using fluorescent imaging (Karl Storz ICG system). Additional ICG 1 ml IV was given after critical view of safety (CVS) was completely dissected. Results: Both patients had CVS visualized with ICG, operation time of 84 and 125 minutes respectively. Conclusion: Compare with intravenous injection, the trans-PTGBD ICG fluorescent cholangiography can provide better signal to noise ratio that only the extrabiliary system, but not the liver parenchyma can be illuminated. However, ICG may enter the lymphatic system through necrotic gallbladder mucosa and inflammatory adhesive tissue, of which lymph spillage during gallbladder dissection can obscure the fluorescent view.