Extrahepatic Biliary Anatomy Research Articles

Intravenous injection versus transhepatic intracholecystic injection of indocyanine green (ICG) to outline biliary tree during laparoscopic cholecystectomy

BackgroundTo potentially lessen injuries and associated complications, fluorescence cholangiography has been suggested as a technique for enhancing the visualization and identification of extrahepatic biliary anatomy. The most popular way to administer indocyanine green (ICG) is intravenously, as there is currently little data on ICG injections directly into the gallbladder. In order to visualize extrahepatic biliary anatomy during laparoscopic cholecystectomy (LC), we compared the two different ICG administration techniques. We also examined variations in visualization time, as well as the effectiveness, benefits, and drawbacks of each modality.MethodsIn this prospective randomized clinical study, 60 consecutive adult patients with chronic and acute gallbladder disease were included. Our study conducted from 2022 to 2024 in Surgical Department of Theodor Bilharz Research Institute. Thirty patients underwent LC with intravenous ICG administration (IV-ICG), thirty patients received a direct injection of gallbladder through transhepatic ICG (IC-ICG) and Preoperative, intraoperative, and postoperative patient data were examined.ResultsIn terms of their perioperative and demographic features, the groups were similar. Without a statistically significant difference, the IV-ICG group’s total operating time was less than that of the IC-ICG group (p 0.140). Compared to the transhepatic IC-ICG method, IV-ICG was more accurate in identifying the duodenum and the common hepatic duct (p = 0.029 and p = 0.016, respectively). In the transhepatic IC-ICG and IV-ICG groups, the cystic duct could be identified prior to dissection in 66.6% and 73.3% of cases, respectively, and this increased to 86.6% and 93.3% following dissection. In the transhepatic IC-ICG group, the common bile duct was visible in 93.3% of cases; in the IV-ICG group, it was visible in 90% of cases. Two cases in the IC-ICG group and every case following IV-ICG administration had liver fluorescence (6.6% versus 100%; p < 0.001).ConclusionThe current study shows that for both administration methods, ICG-fluorescence cholangiography can be useful in identifying the extrahepatic biliary anatomy during Calot’s triangle dissection. By avoiding hepatic fluorescence, the transhepatic IC-ICG route can increase the bile duct-to-liver contrast with less expense and no risk of hypersensitivity reactions than the intravenous ICG injection method. We recommend to use both techniques in case of acute cholecystitis with cystic duct obstruction. In cases of liver cirrhosis, we recommend transhepatic IC-ICG as IV-ICG is limited.

Voice‐over anatomy lectures created by AI‐voice cloning technology: A descriptive article

AbstractThe COVID‐19 pandemic revealed the pivotal role of digital learning and online lecture videos, leading a shift toward blended and flipped classrooms in the post‐pandemic era. This shift calls for development and (or) refreshment of novel online educational resources, such as Voice‐Over PowerPoint (VOPPT) presentations, specifically designed for asynchronous or synchronous learning methods. However, resource limitations often impede the timely delivery of high‐quality instructional materials. In this descriptive article, the use of AI‐voice cloning technology to automate the creation of VOPPT presentation has been explored. Descripts' Overdub tool, an AI‐voice cloning program, was trained on the 15‐min voice sample of an anatomy professor, and the synthesized voice was used to narrate presentations on inguinal canal and extrahepatic biliary anatomy. The educational use of this novel approach was evaluated based on the second‐year undergraduate medical students' qualitative feedback. Voice similarity analysis using Resemblyzer, an open‐source Python tool, showed a high similarity score of 0.92 between the cloned and original voices. Despite this, students raised concerns about the robotic voice, quick pace, punctuation problems, pronunciation difficulties, and expressed reservations about AI‐generated lecture narration. While the cloned voice closely matched the original, the AI‐generated narration fell short of capturing the nuanced details needed for an effective anatomy instruction. This uncovers AI's current limitations in the educational contexts but establishes a foundation for future progress in AI‐voice cloning technologies aimed at enhancing online educational resources for anatomy and medical education.

Feasibilityof Indocyanine Green Fluorescent Cholangiography Via Inguinal Nodal Injection Approachin UpperGastrointestinalOncological Surgeries.A Pilot Study.

Fluorescent cholangiography (FC) with indocyanine green (ICG) is an alternative to intraoperative cholangiography (IOC) for visualizing the biliary tract during surgery. This pilot study assessed the feasibility of ICG-FC using inguinal nodal injection in patients undergoing upper gastrointestinal cancer surgery. Under sonographic guidance, ICG was injected into inguinal nodes bilaterally (each side 2.5mg, total 5mg) after inductionofanesthesia. Laparoscopic cholecystectomy (CHE) and laparoscopic hepatoduodenal ligament clearance (HDL) were performed in 24 cases. ICG-FC was utilized for real-time visualization of extrahepatic biliary anatomy. In CHE cases, ICG-FC provided 100% visualization of the gall bladder (GB), common bile duct (CBD), common hepatic duct (CHD), cystic duct (CD), and CD-CBD junction. For HDL, the visualization rates were 100% for the GB, CHD, and CBD, but only 50% for the undissected CD. Fluorescence appeared in the biliary tree soonafter injection and remained throughout the duration of surgery with minimalinterference frombackground hepaticfluorescence. No adverse reactions to ICG were observed. ICG-FC via the inguinal nodal route is safe and feasible, enabling real-time dissection of the calot's triangle and hepatoduodenal ligament. It offers reliable visualization of key biliary structures, showing promise as an alternative to IOC in upper gastrointestinal cancer surgeries.

Determining the patency of biliary tracts in dogs with gallbladder mucocele using near-infrared cholangiography with indocyanine green.

Cholecystectomy is indicated for gallbladder mucoceles (GBM). Evaluating the patency of the biliary duct and precise biliary tree visualization is crucial for reducing the risk of compromised bile flow after surgery. Therefore, intraoperative cholangiography (IOC) is recommended during cholecystectomy to prevent biliary tract injury. Although indocyanine green (ICG) cholangiography has been extensively reported in human medicine, only one study has been conducted in veterinary medicine. Therefore, this study aimed to demonstrate the use of ICG for IOC to identify fluorescent biliary tract images and determine the patency of the common bile duct during cholecystectomy in dogs. This study comprised 27 dogs, consisting of 17 with gallbladder mucoceles (GBM) and 10 controls, specifically including dogs that had undergone elective cholecystectomy for GBM. ICG injection (0.25 mg/kg) was administered intravenously at least 45 minutes before surgery. During the operation, fluorescent images from cholangiography were displayed on the monitor and obtained in black-and-white mode for the comparison of fluorescence intensity (FI). The FI values of the gallbladders (GBs) and common bile duct (CBD) were measured using FI analyzing software (MGViewer V1.1.1, MetapleBio Inc.). The results demonstrated successful CBD patency identification in all cases. Mobile GBM showed partial gallbladder visibility, whereas immobile GBM showed limited visibility. Additionally, insights into the adequate visualization of the remaining extrahepatic biliary tree anatomy were provided, extending beyond the assessment of CBD patency and gallbladder intensity. Our study demonstrates the potential of fluorescent IOC using intravenous injection of ICG for assessing the patency of the cystic duct and common bile duct during cholecystectomy in patients with GBM, eliminating the need for surgical catheterization and flushing of the biliary ducts. Further research is warranted to investigate and validate the broader applicability of ICG cholangiography in veterinary medicine.

Indocyanine green direct injection into gallbladder during laparoscopic cholecystectomy: a safety method to outline biliary anatomy

Background One of the most frequently done operations in digestive surgery is the laparoscopic cholecystectomy (LC). Despite several safety precautions and guidelines, iatrogenic bile duct damage (BDI) during LC still occurs at a very high incidence. Fluorescence of biliary system may minimise surgical difficulties that might emerge owing to unintended harm to the common bile duct. Methods We outline a technique for directly injecting Indocyanine Green (ICG) into the gallbladder to clarify the architecture of the cystic duct and common bile duct. Fifty patients who underwent elective laparoscopic cholecystectomy participated in the study, which was a randomised controlled clinical trial. Patients who had intraoperative direct injection of ICG into the gallbladder were chosen at random using closed envelope technique, then using near-infrared fluorescence (NIF) imaging during LC) and controls (who underwent standard LC technique) Twenty five patients in each limb. Patients were studied pre-operative, intraoperative &amp; postoperative. 50 patients in all, 25 of whom received LC with intracholecystic ICG injection, and 25 of whom underwent standard LC without the use of ICG, were included in our study. Results ICG dye was successful to delineate extrahepatic biliary anatomy well in 20 cases out of 25, while without ICG, 9 cases out of 25 were without clear delineation of common bile duct intraoperative even if cystic duct was clear enough to avoid complications in both groups . Operative Time average in cases with ICG-assisted LC was 78±15.0 min which was less than the average of time consumed in LC without ICG to dissect cystic duct and visualize critical view of safety, 101±11.87 min Conclusion Direct gallbladder ICG infusion enables quick extrahepatic biliary system imaging and clarifies the dissection, increasing protection against BDI and reducing intraoperative dissection time.

Intracholecystic versus Intravenous Indocyanine Green (ICG) Injection for Biliary Anatomy Evaluation by Fluorescent Cholangiography during Laparoscopic Cholecystectomy: A Case-Control Study.

(1) Background: Fluorescence cholangiography has been proposed as a method for improving the visualization and identification of extrahepatic biliary anatomy in order to possibly reduce injuries and related complications. The most common method of indocyanine green (ICG) administration is the intravenous route, whereas evidence on direct ICG injection into the gallbladder is still quite limited. We aimed to compare the two different methods of ICG administration in terms of the visualization of extrahepatic biliary anatomy during laparoscopic cholecystectomy (LC), analyzing differences in the time of visualization, as well as the efficacy, advantages, and disadvantages of both modalities. (2) Methods: A total of 35 consecutive adult patients affected by acute or chronic gallbladder disease were enrolled in this prospective case–control study. Seventeen patients underwent LC with direct gallbladder ICG injection (IC-ICG) and eighteen subjects received intravenous ICG administration (IV-ICG). (3) Results: The groups were comparable with regard to their demographic and perioperative characteristics. The IV-ICG group had a significantly shorter overall operative time compared to the IC-ICG group (p = 0.017). IV-ICG was better at delineating the duodenum and the common hepatic duct compared to the IC-ICG method (p = 0.009 and p = 0.041, respectively). The cystic duct could be delineated pre-dissection in 76.5% and 66.7% of cases in the IC-ICG and IV-ICG group, respectively, and this increased to 88.2% and 83.3% after dissection. The common bile duct could be highlighted in 76.5% and 77.8% of cases in the IC-ICG and IV-ICG group, respectively. Liver fluorescence was present in one case in the IC-ICG group and in all cases after IV-ICG administration (5.8% versus 100%; p < 0.0001). (4) Conclusions: The present study demonstrates how ICG-fluorescence cholangiography can be helpful in identifying the extrahepatic biliary anatomy during dissection of Calot’s triangle in both administration methods. In comparison with intravenous ICG injection, the intracholecystic ICG route could provide a better signal-to-background ratio by avoiding hepatic fluorescence, thus increasing the bile duct-to-liver contrast.

Study of Learning Curve in a Surgeon for Near-Infrared Fluorescence Cholangiography During Laparoscopic Cholecystectomy-A Retrospective Evaluation.

Near-infrared indocyanine green fluorescence cholangiography (NIRF) has shown promising results on delineating extra-hepatic biliary anatomy during laparoscopic cholecystectomy to avoid bile duct injury. However its routine usage remains in question. In this study, the technique was evaluated further with learning curve estimation and learning factors were observed. One hundred ninety-nine cases which underwent laparoscopic cholecystectomy for acute or chronic cholecystitis within a 2-year period including 51 cases with initial use of NIRF by 2 surgeons were studied retrospectively. The learning curve was evaluated for a surgeon as primary objective. A case-matched comparison of the operative time between NIRF and conventional group, in terms of acute and chronic cholecystitis was also conducted as a secondary calculation. Learning curve was evaluated with 61% learning rate for NIRF experience. Cysto-biliary junction non-illuminated cases under fluorescent view, had mean operative time of 80.83 ± 22.82min, which was shorter than the cysto-biliary junction illuminated cases. The NIRF group exhibited longer operative time compared with the conventional group with mean difference of 34.39min (significant at P < .05). While the initial learning phase might be affected by surgeons' behavior and attitude, our results may provide a reference to learn at one's own pace and to employ NIRF teaching strategies during surgical training programs to overcome the initial phase during training period itself and facilitate universal achievement.

Near infrared indocyanine green fluorescent cholangiography versus intraoperative cholangiography to improve safety in laparoscopic cholecystectomy for gallstone disease\u2014a systematic review protocol

BackgroundLaparoscopic cholecystectomy has become the standard surgical approach in the treatment of cholelithiasis. Diverse surgical techniques and different imaging modalities have been described to evaluate the biliary anatomy and prevent or early detect bile duct injuries. X-ray intraoperative cholangiography (IOC) and near infrared indocyanine green fluorescent cholangiography (NIR-ICG) are safe and feasible techniques to assess biliary anatomy. The aim of this systematic review will be to evaluate if NIR-ICG can visualize extrahepatic biliary anatomy more efficiently and safer than IOC in minimally invasive cholecystectomy for gallstone disease.MethodsLiterature search will be performed via MEDLINE (PubMed), Embase, Scopus, the Cochrane Central Register of Controlled Trials, and Web of Science Core Collection from 2009 to present. All randomized controlled clinical trials and prospective non-randomized controlled trials which report on comparison of NIR-ICG versus IOC will be included. All patients over 18 years old who require elective or urgent minimally invasive cholecystectomy (undergoing NIR-ICG during this procedure) due to gallstone disease both acute and chronic will be included. Since BDI has a low incidence, the primary outcome will be the ability to visualize extrahepatic biliary anatomy and the time to obtain relevant images of these structures.Two researchers will individually screen the identified records, according to a list of inclusion and exclusion criteria. Bias of the studies will be evaluated with the Newcastle-Ottawa score for non-randomized studies and with The Cochrane Risk of Bias Tool for randomized controlled trials. Quality of evidence for all outcomes will be determined with the GRADE system. The data will be registered in a predesigned database. If selected studies are sufficiently homogeneous, we will perform a meta-analysis of reported results. In the event of a substantial heterogeneity, a narrative synthesis will be provided. Subgroup analysis will be used to investigate possible sources of heterogeneity.DiscussionUnderstanding the benefits of this technique is critical to ensuring policymakers can make informed decisions as to where preventive efforts should be focused regarding specific imaging techniques. If ICG is proven to be faster and non-invasive, its routine use could be encouraged.Systematic review registrationPROSPERO CRD42020177991.

A Study of Anatomical Variations of Extrahepatic Biliary System by Pre-operative Magnetic Resonance Cholangio-Pancreatography and that Encountered during Laparoscopic Cholecystectomy: A Prospective Observational Study

Introduction: The variations in cystic duct anatomy are of considerable importance during surgical excision of the gallbladder (cholecystectomy). Preoperative MRCP assessment of possible anatomical variations helps the surgeon to formulate appropriate strategies and operative planning. Objective: To assess the usefulness of pre-operative MRCP assessment of anatomical variations of extra-hepatic biliary tree in surgical planning and validate the MRCP findings with surgical findings. Material and Method: A total 120 patients of ultrasonography proven gallstone disease were included in the study, further evaluated preoperatively by magnetic resonance cholangio-pancreatography for delineation of extra-hepatic biliary anatomy and that was compared with findings during Laparoscopic Cholecystectomy performed in the same patients. Seven patients had frozen Calot’s triangle per-operatively and were excluded from the study. Results: Majority of patients was in age group of 51-60 years (28.4%) and females (85.84%). on MRCP, Posterior insertion of Cystic duct was noted in 58.41% patients, Lateral insertion in 35.39% patients while on per-operatively Posterior insertion was noted in 50.44% and lateral insertion in 38.94 % patients. Most common intra-op complication was Bile spill in 19.4% patients, Stone spill in 9.7% patients and there was no bile duct injury noted. Conclusion: There is a definitive role of magnetic resonance cholangio-pancreatography prior to laparoscopic cholecystectomy in gallstone disease for precisely delineating the extra hepatic biliary tree anatomy and predicting difficult surgery thus helping the surgeon to be prepared for the eventualities during surgery and to prevent biliary injury. However still intra-op picture can vary and overall, there is reduction in patient morbidity.

Systematic review of the role of indocyanine green near-infrared fluorescence in safe laparoscopic cholecystectomy (Review).

With the widespread introduction of laparoscopic cholecystectomy, the incidence of iatrogenic main bile duct lesions has significantly increased, with incidences ranging from 0.2 to 1.5% according to current studies. Although there are studies regarding the use of indocyanine green (ICG) for improved visualization of the biliary anatomy, there is no consensus on the dose, timing and optimal mode of administration, or the indications in which ICG provides a real benefit through increased safety in laparoscopic cholecystectomy (LC). A systematic review was performed on articles in English published until March 2021, which were identified on PubMed, Springer Nature, Elsevier and Scopus via specific mesh terms: 'Indocyanine green'/'near-infrared fluorescence' and 'laparoscopic cholecystitis'. The most used method of administration of ICG was intravenously, only one study evaluated the efficiency of a near-infrared cholangiogram (NIRC) when ICG was administered directly in the gallbladder. The majority of the studies included in the review used 2.5 mg of ICG administered within 1 h before imaging. The intensity of the NIRC fluorescence signal was revealed to depend on several factors, with obesity and inflammation as the most clinically significant. NIRC was reported to be a simple, feasible, safe and cost-effective procedure, which may improve safety in difficult cases of LC. NIRC use in combination with white light has been demonstrated to be superior to white light alone in identifying extrahepatic biliary anatomy, thus decreasing the risk of intraoperative bile duct injuries (BDI). For its large-scale use, data on a higher number of patients to confirm its clinical value and specific indications is required.

Indocyanine green (ICG) fluorescent cholangiography during laparoscopic cholecystectomy using RUBINA\u2122 technology: preliminary experience in two pediatric surgery centers

BackgroundRecently, we reported the feasibility of indocyanine green (ICG) near-infrared fluorescence (NIRF) imaging to identify extrahepatic biliary anatomy during laparoscopic cholecystectomy (LC) in pediatric patients. This paper aimed to describe the use of a new technology, RUBINA™, to perform intra-operative ICG fluorescent cholangiography (FC) in pediatric LC.MethodsDuring the last year, ICG-FC was performed during LC using the new technology RUBINA™ in two pediatric surgery units. The ICG dosage was 0.35 mg/Kg and the median timing of administration was 15.6 h prior to surgery. Patient baseline, intra-operative details, rate of biliary anatomy identification, utilization ease, and surgical outcomes were assessed.ResultsThirteen patients (11 girls), with median age at surgery of 12.9 years, underwent LC using the new RUBINA™ technology. Six patients (46.1%) had associated comorbidities and five (38.5%) were practicing drug therapy. Pre-operative workup included ultrasound (n = 13) and cholangio-MRI (n = 5), excluding biliary and/or vascular anatomical anomalies. One patient needed conversion to open surgery and was excluded from the study. The median operative time was 96.9 min (range 55–180). Technical failure of intra-operative ICG-NIRF visualization occurred in 2/12 patients (16.7%). In the other cases, ICG-NIRF allowed to identify biliary/vascular anatomic anomalies in 4/12 (33.3%), including Moynihan's hump of the right hepatic artery (n = 1), supravescicular bile duct (n = 1), and short cystic duct (n = 2). No allergic or adverse reactions to ICG, post-operative complications, or reoperations were reported.ConclusionOur preliminary experience suggested that the new RUBINA™ technology was very effective to perform ICG-FC during LC in pediatric patients. The advantages of this technology include the possibility to overlay the ICG-NIRF data onto the standard white light image and provide surgeons a constant fluorescence imaging of the target anatomy to assess position of critical biliary structures or presence of anatomical anomalies and safely perform the operation.

Volvulus of the gallbladder: Beware of aberrant biliary anatomy

Gallbladder volvulus (GBV) is an uncommon differential in the acute surgical abdomen, which may incur significant morbidity if missed. Less than 500 cases have been reported in the literature, with few diagnosed pre-operatively. It is defined as the rotation of the gallbladder on its mesentery along the axis of the cystic pedicle, although cases of torsion of the gallbladder fundus itself have been reported. An 82-year-old lady presented with a worsening 5 day history of right upper quadrant pain with associated nausea, anorexia. She had worsening pain and noticed a 'lump' in her abdomen, along with subjective fevers. On examination, her abdomen was tender, with a non-pulsatile mass in the RUQ with voluntary guarding. The computed tomography Abdo-Pelvis revealed a distended gallbladder extended up to the pelvis with multiple gallstones. Stranding of fat around the gallbladder was noted, with wall thickening up to 7 mm at the fundus - with overall appearances consistent with acute cholecystitis. An open cholecystectomy was performed, with the intraoperative finding of GBV. There were multiple small arteries supplying the gallbladder, with no definitive cystic artery. The extra-hepatic biliary anatomy was aberrant with a long-cystic duct exiting through the cystic plate. Post-operatively recovery was uncomplicated. GBV is an important differential of RUQ pain, requiring immediate intervention. It is often misdiagnosed as cholecystitis. Imaging is variable in detecting GBV, and early surgical intervention remains the mainstay of both diagnosis and treatment. However, surgeons should beware that unrecognized aberrant biliary anatomy can result in higher morbidity.

The role of indocyanine green cholangiography in minimally invasive surgery.

Near-infrared fluorescent cholangiography (NIFC) using indocyanine green (ICG) is increasingly used to aid in the identification of extrahepatic biliary anatomy. The use of ICG cholangiography for laparoscopic cholecystectomy is suggested to be safe and feasible. This article aimed at reviewing the dosage and timing of the intravenous administration of ICG, its efficacy and potential usage. MEDLINE and PubMed searches were performed using the key words "fluorescent cholangiography," "ICG cholangiography," "near-infrared fluorescent cholangiography" and "laparoscopic cholecystectomy" to identify relevant articles published in English during the years of 2010 to 2020. Reference lists from the articles were reviewed to identify additional pertinent articles. Several factors can influence the quality of the fluorescence imaging, including the dose and timing of ICG injection, liver function, the thickness of fatty tissue and the presence of inflamed tissues due to acute pathology. Various devices tested also have a different sensitivity to the fluorescence signal. RCTs showed fluorescence cholangiography were comparable to traditional intraoperative cholangiogram in visualizing the extrahepatic biliary anatomy. However, there is still no consensus in the dosing of ICG and the time interval between ICG injection and detection of biliary fluorescence. Fluorescence cholangiography's ability to enhance such visualization can potentially reduce bile duct injury risks and shorten the operative time. However, no valuable data for bile duct injury prevention or detection could be retrieved. NIFC is demonstrated as a safe, non-irradiating technique to identify and aid in the visualization of extrahepatic biliary anatomy. Laparoscopic cholecystectomy with real-time NIFC enables a better visualization and identification of biliary anatomy and therefore it is potentially as a means of increasing the safety of laparoscopic cholecystectomy. Whether this translates into reducing complication rates must still be determined. The dosage and timing of the intravenous administration of ICG relative to the operative procedure still requires optimization to ensure reliable images.

Is Routine MRCP Needed in Symptomatic Gallstone Disease? - A Single Center Experience

Objectives: To assess the role of magnetic resonance cholangiopancreatography (MRCP) in the detection of choledocholithiasis in patients with symptomatic gallstone disease and to determine the anatomical variations of extra hepatic biliary tract and their relation to bile duct injury during laparoscopic cholecystectomy. Methods: This is a retrospective observational study of 80 patients from a prospectively maintained database from October 2017 to September 2019. On the basis of findings from Preoperative liver function test and Ultrasound abdomen, patients were divided into 3 groups as per ASGE guidelines for the risk of choledocholithiasis[high risk(n=14),medium risk(n=13),low/no risk(n=53)]. MRCP was performed in all patients routinely. Results: MRCP detected choledocholithiasis in 14 patients. 9 out of 14 patients had dilated CBD on Ultrasound and 7 had elevated ALP. Among 66 patients without CBD stone, ALP was elevated in 4 patients. Patients with MRCP detected stones were subjected to ERCP which was successful in 9 patients. From remaining 5 patients with unsuccessful ERCP, two patients underwent laparoscopic CBD exploration/T tube drainage, one patient underwent bilioenteric anastomosis, two patients with biliary pancreatitis were managed with laparoscopic cholecystectomy alone in view of passed out stone. MRCP diagnosed extrahepatic biliary tract variations in 15% cases(n=12). No patient suffered bile duct injury in this study. Conclusion: In view of high sensitivity to detect choledocholithiasis even in normal LFT and USG abdomen and to delineate extrahepatic biliary anatomy, we suggest routine MRCP in all cases of symptomatic gallstone disease to aid in preoperative management and prevention of bile duct injury.

Risk of Gallstone Formation in Aberrant Extrahepatic Biliary Tract Anatomy: A Review of Literature.

The age-long mnemonic of '5Fs' (fat, female, fertile, forty, and fair) has traditionally been used in medical school instructions to describe the risk factors for gallstone disease. However, evidence suggests that aberrant extrahepatic biliary tract (EHBT) anatomy may contribute significantly to the risk of gallstone disease. This review explores the anatomy and embryological bases of EHBT variations as well as the prevalence of these variations. Also, we discuss the risk factors for gallstone formation in the relationship between gallstone disease and aberrant EHBT anatomy.

Evaluation of intrahepatic and extrahepatic biliary tree anatomy and its variation by magnetic resonance cholangiopancreatography in Odisha population: a retrospective study.

Intrahepatic and extrahepatic anatomical knowledge is essential for pre procedural planning of liver transplantation, liver resection, complex biliary reconstruction and radiological biliary tree intervention. Indian data of biliary anatomy and its variation is scant in literature. The aim of our study is to find out the prevalence of common and uncommon pattern of biliary tree anatomy in magnetic resonance cholangiopancreatography (MRCP) in our population. A total of 1,038 cases of MRCP of population of Odisha were obtained from Picture Archiving and Communication System of the department and were reviewed by two senior radiologists for anatomical pattern and variations. The typical and most common pattern of right hepatic duct (RHD) branching was seen in 72.8% cases. The most common variant of RHD was trifurcation pattern of insertion of right anterior sectoral duct (RASD), right posterior sectoral duct and left hepatic duct (LHD) forming common hepatic duct (CHD) in 11.3% of cases. The common trunk of segment (SEG) II and III ducts joining the SEG IV duct was the most common LHD branching pattern in 90.3% of cases. The most common pattern of cystic duct was posterior insertion to middle third of CHD (42.8%). MRCP is the non-invasive imaging modality for demonstration of biliary duct morphology to prevent iatrogenic injury during hepatobiliary intervention and surgery.

Direct Gallbladder Indocyanine Green Injection Fluorescence Cholangiography During Laparoscopic Cholecystectomy

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.

A Technique to Define Extrahepatic Biliary Anatomy Using Robotic Near-Infrared Fluorescent Cholangiography

BackgroundBile duct injury is a rare but serious complication of minimally invasive cholecystectomy. Traditionally, intraoperative cholangiogram has been used in difficult cases to help delineate anatomical structures, however, new imaging modalities are currently available to aid in the identification of extrahepatic biliary anatomy, including near-infrared fluorescent cholangiography (NIFC) using indocyanine green (ICG).1-5 The objective of the study was to evaluate if this technique may aid in safe dissection to obtain the critical view. MethodsThirty-five consecutive multiport robotic cholecystectomies using NIFC with ICG were performed using the da Vinci Firefly Fluorescence Imaging System. All patients received 2.5 mg ICG intravenously at the time of intubation, followed by patient positioning, draping, and establishment of pneumoperitoneum. No structures were divided until the critical view of safety was achieved. Real-time toggling between NIFC and bright-light illumination was utilized throughout the case to define the extrahepatic biliary anatomy. ResultsICG was successfully administered to all patients without complication, and in all cases the extrahepatic biliary anatomy was able to be identified in real-time 3D. All procedures were completed without biliary injury, conversion to an open procedure, or need for traditional cholangiography to obtain the critical view. Specific examples of cases where x-ray cholangiography or conversion to open was avoided and NIFC aided in safe dissection leading to the critical view are demonstrated, including (1) evaluation for aberrant biliary anatomy, (2) confirmation of non-biliary structures, and (3) use in cases where the infundibulum is fused to the common bile duct. ConclusionNIFC using ICG is demonstrated as a useful technique to rapidly identify and aid in the visualization of extrahepatic biliary anatomy. Techniques that selectively utilize this technology specifically in difficult cases where the anatomy is unclear are demonstrated in order to obtain the critical view of safety.

Direct Gallbladder Indocyanine Green Injection Fluorescence Cholangiography During Laparoscopic Cholecystectomy.

Intravenous injection of indocyanine green (ICG) is used to illuminate extrahepatic biliary anatomy. Fluorescence of biliary structures may lower surgical complications that can arise due to inadvertent injury to the common bile duct. We describe a method of injecting ICG directly into the gallbladder to define the cystic duct and common bile duct anatomy. A standard laparoscopic cholecystectomy was performed 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 fluoresce the gallbladder, cystic duct, and common bile duct structures. Eleven 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, the dissection plane between the gallbladder and the liver is highlighted with the gallbladder ICG fluorescence. Direct gallbladder ICG injection provides immediate visualization of extrahepatic biliary structures and clarifies the dissection plane between the gallbladder and the liver bed.

A technique to define extrahepatic biliary anatomy using robotic near-infrared fluorescent cholangiography

A technique to define extrahepatic biliary anatomy using robotic near-infrared fluorescent cholangiography