Near-Infrared Cholangiography Can Facilitate a Laparoscopic Choledocholithotomy Even After Upper Abdominal Surgery

Abstract

Introduction: Surgery for common bile duct (CBD) stones is challenging while unclear hepatic hilum anatomy especial experience of previous laparotomy. A minimally-invasive approach choledocholithotomy can be difficult and converted for the unclear biliary anatomy. Near-infrared (NIR) cholangiography by systemic administration of Indocyanine Green (ICG) can enhance the visualization of the biliary tree anatomy but is limited by the high intensity of background fluorescence signal coming from the liver. NIR fluorescence cholecysto-cholangiography by direct biliary tree administration of the ICG can enhance the biliary tree without background noise signal. We created the NIR cholangiography via different route according to patient situation : systemic circulation or biliary tree injection to see the feasibility of those application Method: Ten patients who suffered from obstructive jaundice due to CBD stone and 5 patients received percutaneous biliary tree drainage as first treatment and 2 patients received endoscopic biliary tree drainage. Those patients received laparoscopic choledocholithotomy as definite treatment after acute infection phase. 5 patients received biliary tree ICG injection via drain tube and 5 patients by systemic injection. Visualization and fluorescence patterns around CBD was recorded Result: In our series, one patient received previous gastrectomy and 4 patients had previous biliary tree surgery. 2 Patients received PTGBD and 3 patient received PTCD for biliary decompression. The near infra-red cholangiography of ten patients can show the clear margin of CBD. No intra or postoperative complications noted. Median time to CBD localization after ICG injection was 5.2 sec for biliary tree injection and 35 minutes for systemic injection. One patient converted to open method due to big stone impaction in distal CBD. No mortality and mobidity were found. Conclusion: Fluorescence cholangiography with ICG injection could provide visualization of CBD even inflammatory or post operative adhesion status, and direct injection method provide more real-time and noise-free image than systemic injection.