Extrahepatic Biliary Anatomy Research Articles

Intraoperative Laparoscopic Near-Infrared Fluorescence Cholangiography to Facilitate Anatomical Identification: When to Give Indocyanine Green and How Much.

Recent technological advances have enabled real-time near-infrared fluorescence cholangiography (NIRFC) with indocyanine green (ICG). Whereas several studies have shown its feasibility, dosing and timing for practical use have not been optimized. We undertook a prospective study with systematic variation of dosing and timing from injection of ICG to visualization. Adult patients undergoing laparoscopic biliary and hepatic operations were enrolled. Intravenous ICG (0.02-0.25 mg/kg) was administered at times ranging from 10 to 180 minutes prior to planned visualization. The porta hepatis was examined using a dedicated laparoscopic system equipped to detect NIRFC. Quantitative analysis of intraoperative fluorescence was performed using a scoring system to identify biliary structures. A total of 37 patients were enrolled. Visualization of the extrahepatic biliary tract improved with increasing doses of ICG, with qualitative scores improving from 1.9 ± 1.2 (out of 5) with a 0.02-mg/kg dose to 3.4 ± 1.3 with a 0.25-mg/kg dose (P < .05 for 0.02 vs 0.25 mg/kg). Visualization was also significantly better with increased time after ICG administration (1.1 ± 0.3 for 10 minutes vs 3.4 ± 1.1 for 45 minutes, P < .01). Similarly, quantitative measures also improved with both dose and time. There were no complications from the administration of ICG. These results suggest that a dose of 0.25 mg/kg administered at least 45 minutes prior to visualization facilitates intraoperative anatomical identification. The dosage and timing of administration of ICG prior to intraoperative visualization are within a range where it can be administered in a practical, safe, and effective manner to allow intraoperative identification of extrahepatic biliary anatomy using NIRFC.

Adenomyomatosis of the gallbladder in childhood: A systematic review of the literature and an additional case report.

To investigate the diagnostic and therapeutic assessment in children with adenomyomatosis of the gallbladder (AMG). AMG is a degenerative disease characterized by a proliferation of the mucosal epithelium which deeply invaginates and extends into the thickened muscular layer of the gallbladder, causing intramural diverticula. Although AMG is found in up to 5% of cholecystectomy specimens in adult populations, this condition in childhood is extremely uncommon. Authors provide a detailed systematic review of the pediatric literature according to PRISMA guidelines, focusing on diagnostic and therapeutic assessment. An additional case of AMG is also presented. Five studies were finally enclosed, encompassing 5 children with AMG. Analysis was extended to our additional 11-year-old patient, who presented diffuse AMG and pancreatic acinar metaplasia of the gallbladder mucosa and was successfully managed with laparoscopic cholecystectomy. Mean age at presentation was 7.2 years. Unspecific abdominal pain was the commonest symptom. Abdominal ultrasound was performed on all patients, with a diagnostic accuracy of 100%. Five patients underwent cholecystectomy, and at follow-up were asymptomatic. In the remaining patient, completely asymptomatic at diagnosis, a conservative approach with monthly monitoring via ultrasonography was undertaken. Considering the remote but possible degeneration leading to cancer and the feasibility of laparoscopic cholecystectomy even in small children, evidence suggests that elective laparoscopic cholecystectomy represent the treatment of choice. Pre-operative evaluation of the extrahepatic biliary tree anatomy with cholangio-MRI is strongly recommended.

An incidental finding of absent gall bladder in laparoscopic exploration - a rare occurrence in extra hepatic biliary anatomy

An incidental finding of absent gall bladder in laparoscopic exploration - a rare occurrence in extra hepatic biliary anatomy

Routine use of fluorescent incisionless cholangiography as a new imaging modality during laparoscopic cholecystectomy.

Intraoperative incisionless fluorescent cholangiography (IOIFC) has been described to identify extrahepatic biliary anatomy. Potential advantages of the routine use of intraoperative incisionless fluorescent cholangiography were evaluated in a consecutive series of cases. A total of 45 patients undergoing laparoscopic cholecystectomy between January and July 2013 were consented and included in this study. We analyzed a prospectively collected database for feasibility, cost, time, usefulness, teaching tool, safety, learning curve, X-ray exposure, complexity, and real-time surgery of IOIFC. A single dose of 0.05 mg/kg of Indocyanine green was administered prior to surgery. During the procedure, a laparoscopic fluorescence system was used. IOIFC could be performed in all 45 patients, whereas intraoperative cholangiography could be performed in 42 (93 %). Individual median cost of performing IOFC was cheaper than IOC (13.97 ± 4.3 vs 778.43 ± 0.4 USD) per patient, p = 0.0001). IOFC was faster than IOC (0.71 ± 0.26 vs 7.15 ± 3.76 minutes, p < 0.0001). The cystic duct was identified by IOFC in 44 out of 45 patients (97.77 %). IOIFC appears to be a feasible, low-cost, expeditious, useful, and effective imaging modality when performing LC. It is safe, easy to perform and interpret, and does not require a learning curve or X-ray. It can be used for real time surgery to delineate the extrahepatic biliary structures.

The Unusual Localization of Right Hepatic Artery Multiple Anatomic Variants in Celiac Axis

The extrahepatic vascular and biliary anatomy of Calot’s triangle is well known to be highly variable and this provides a surgical challenge. The liver has a dual blood supply consisting of the portal vein and the hepatic artery. The hepatic artery which delivers 25% of the blood supply, arises from the celiac trunk. The celiac trunk gives off the left gastric, splenic and common hepatic arteries. The common hepatic artery then divides into gastroduodenal artery and hepatic artery proper which diverts in right and left hepatic arteries. The systic artery usually originates from the right hepatic artery. The “classic” arterial anatomy is present in approximately 75% of cases. The remaining 25% of the cases have many anatomical variants. Here in we present a patient with multiple anatomic variants in celiac trunk which were determined incidentally during laparoscopic cholecystectomy. Being aware of the arterial variations in the liver is really important in surgical procedures in order to avoid bleeding and ischemia.

Intra‐operative fluorescent cholangiography using indocyanin green during robotic single site cholecystectomy

Very recently, robotic single site cholecystectomy (RSSC) has been reported feasible and safe for selected cases. While an intra-operative cholangiography can be performed, data is scarce with respect to its use. Indocyanin green (ICG) has been shown to be a viable option to visualize biliary anatomy. Since the introduction of a new near infrared camera integrated to the da Vinci Si System (Intuitive Surgical, Sunnyvale, CA), the surgeon is able to assess the biliary anatomy by a non-invasive and non-ionizing method. This paper presents the first report of ICG imaging during a RSSC. Twelve consecutive patients presenting symptomatic cholelithiasis were prospectively enrolled. They underwent RSSC approximately 45 minutes after intravenous administration of ICG (2.5 mg). The biliary anatomy was analyzed using a near infrared camera integrated to the robot before and after the robotic dissection. Eight women and four men underwent the procedure. There was a port addition in one case and no peri-operative complications. Mean operative time was 85 minutes (range: 57-125). The cystic, common bile and common hepatic ducts were recognized by fluorescence imaging before the dissection in 91.7%, 50%, and 33.3% of patients, respectively. At least one structure was visualized in 100% of patients. After the completion of Calot's triangle dissection, the cystic, common bile, and common hepatic ducts were recognized in 100%, 83.3%, and 66.7% of cases respectively. RSSC using ICG for biliary tree fluorescence imaging can be performed safely. Fluorescent cholangiography enabled real-time identification of the extra-hepatic biliary anatomy using a near infrared camera integrated to the robot. Its routine clinical use merits further investigations.

Fluorescence-Guided Laparoscopic Cholecystectomy

Safe cholecystectomy requires confident identification of extrahepatic biliary anatomy. This is the first report of the use of fluorescein and ultraviolet light to improve visualization of biliary topography during laparoscopic cholecystectomy. Five patients who had symptomatic gallstones underwent laparoscopic cholecystectomy with intraoperative intravenous fluorescein injection. Ultraviolet A from an LED light source was used to induce fluorescence of bile. It was delivered by a device that was designed and built by the authors. Within 4 to 5 minutes the bile ducts were shining with green fluorescence and were easily differentiated from the surrounding tissues. In all cases, identification of the extrahepatic biliary anatomy by the fluorescence technique preceded its identification with conventional white light. Fluorescence remained for the whole duration of operation that extended for 42 to 77 minutes. At laparoscopic cholecystectomy, intravenous fluorescein injection and ultraviolet A excitation induce bile ducts to fluoresce. The technique allows better and earlier real-time visualization of biliary anatomy than conventional white light. The technique is simple and inexpensive. It serves as an additional tool that would improve safety of laparoscopic cholecystectomy.

Intraoperative Near‐infrared Fluorescent Cholangiography (NIRFC) in Mouse Models of Bile Duct Injury: Reply

Accidental injury to the common bile duct is a rare but serious complication of laparoscopic cholecystectomy. Accurate visualization of the biliary ducts may prevent injury or allow its early detection. Conventional X-ray cholangiography is often used and can mitigate the severity of injury when correctly interpreted. However, it may be useful to have an imaging method that could provide real-time extrahepatic bile duct visualization without changing the field of view from the laparoscope. The purpose of the present study was to test a new near-infrared (NIR) fluorescent agent that is rapidly excreted via the biliary route in preclinical models to evaluate intraoperative real-time near infrared fluorescent cholangiography (NIRFC). To investigate probe function and excretion, a lipophilic near-infrared fluorescent agent with hepatobiliary excretion was injected intravenously into one group of C57/BL6 control mice and four groups of C57/BL6 mice under the following experimentally induced conditions: (1) chronic biliary obstruction, (2) acute biliary obstruction (3) bile duct perforation, and (4) choledocholithiasis, respectively. The biliary system was imaged intravitally for 1 h with near-infrared fluorescence (NIRF) with an intraoperative small animal imaging system (excitation 649 nm, emission 675 nm). The extrahepatic ducts and extraluminal bile were clearly visible due to the robust fluorescence of the excreted fluorochrome. Twenty-five minutes after intravenous injection, the target-to-background ratio peaked at 6.40 ± 0.83 but signal was clearly visible for ~60 min. The agent facilitated rapid identification of biliary obstruction and bile duct perforation. Implanted beads simulating choledocholithiasis were promptly identifiable within the common bile duct lumen. Near-infrared fluorescent agents with hepatobiliary excretion may be used intraoperatively to visualize extrahepatic biliary anatomy and physiology. Used in conjunction with laparoscopic imaging technologies, the use of this technique should enhance hepatobiliary surgery.

Anomalous Hepatopancreatic Duct: a Case Report

The variation of extrahepatic biliary anatomy is useful for a surgeon during surgeries on gall bladder, duodenum and pancreas. A sound knowledge of the normal anatomy of the extrahepatic biliary tract is thus essential in the prevention of operative injury to it. We present a rare case of hepatopancreatic duct which is unusually long and opening into the third part of duodenum.

Intraoperative Near‐Infrared Fluorescent Cholangiography (NIRFC) in Mouse Models of Bile Duct Injury

Accidental injury to the common bile duct is a rare but serious complication of laparoscopic cholecystectomy. Accurate visualization of the biliary ducts may prevent injury or allow its early detection. Conventional X-ray cholangiography is often used and can mitigate the severity of injury when correctly interpreted. However, it may be useful to have an imaging method that could provide real-time extrahepatic bile duct visualization without changing the field of view from the laparoscope. The purpose of the present study was to test a new near-infrared (NIR) fluorescent agent that is rapidly excreted via the biliary route in preclinical models to evaluate intraoperative real-time near infrared fluorescent cholangiography (NIRFC). To investigate probe function and excretion, a lipophilic near-infrared fluorescent agent with hepatobiliary excretion was injected intravenously into one group of C57/BL6 control mice and four groups of C57/BL6 mice under the following experimentally induced conditions: (1) chronic biliary obstruction, (2) acute biliary obstruction (3) bile duct perforation, and (4) choledocholithiasis, respectively. The biliary system was imaged intravitally for 1 h with near-infrared fluorescence (NIRF) with an intraoperative small animal imaging system (excitation 649 nm, emission 675 nm). The extrahepatic ducts and extraluminal bile were clearly visible due to the robust fluorescence of the excreted fluorochrome. Twenty-five minutes after intravenous injection, the target-to-background ratio peaked at 6.40 +/- 0.83 but signal was clearly visible for ~60 min. The agent facilitated rapid identification of biliary obstruction and bile duct perforation. Implanted beads simulating choledocholithiasis were promptly identifiable within the common bile duct lumen. Near-infrared fluorescent agents with hepatobiliary excretion may be used intraoperatively to visualize extrahepatic biliary anatomy and physiology. Used in conjunction with laparoscopic imaging technologies, the use of this technique should enhance hepatobiliary surgery.

A comparison of MR cholangiopancreatography at 1.5 and 3.0 Tesla

Clinical MR systems operating at 3.0 Tesla have the potential to significantly improve spatial resolution due to the boost in intrinsic signal to noise ratio. However, body imaging at these field strengths presents a number of technical challenges. We performed a prospective pilot study in which 10 patients underwent an MR cholangiopancreatography (MRCP) examination consecutively on 1.5 and 3.0 Tesla systems (both Philips Intera). An axial half Fourier segmented turbo spin echo (HASTE) sequence and a coronal thick-slab 2D turbo-spin echo (TSE) sequence were compared on both systems. A reader measured the signal intensity (SI) ratios of common bile duct (CBD): liver, and CBD: fat on HASTE images and CBD: liver on the TSE images. A second reader performed a qualitative analysis of the intrahepatic and extrahepatic biliary anatomy. Quantitative data was compared using the paired t-test and qualitative data with the paired Wilcoxon signed rank test with p < 0.05. The quantitative analysis of the HASTE sequences showed a slightly higher signal intensity ratio (CBD:liver) at 3.0 Tesla compared with 1.5 Tesla (8.1 vs 5.6, p = 0.002). No significant difference was found between the SI ratios of (CBD:fat) on HASTE images or (CBD:liver) on TSE images. The qualitative analysis showed superior image quality of 3.0 Tesla over 1.5 Tesla images on both HASTE (31 vs 25, p = 0.032), and TSE sequences (34 vs 28, p = 0.043). This pilot study shows that MRCP is feasible at 3.0 Tesla with some improvement in image quality and signal characteristics. Further development may be achieved with sequence optimization and improved coil design.

Biliary tract anomalies in thoraco-omphalopagus conjoined twins

Thoraco-omphalopagus conjoined twins were separated urgently on the ninth day of life because of bowel obstruction and impending intestinal perforation. Preoperative studies clarified the cardiac, intestinal, and hepatic parenchymal anomalies, but the precise biliary anatomy remained obscure. Operative cholangiogram through the single gallbladder visualized only the extrahepatic biliary anatomy in twin A. At reoperation for abdominal patch removal, exploration in twin A found biliary atresia. Because of the unusual duodenal anatomy and extreme short bowel, the authors elected to treat the biliary atresia in twin A with an appendix portoenterostomy. Twin B had no gallbladder and a profoundly hypoplastic biliary tree. Both twins have normal bilirubin and liver function at 18 months of age. The anatomic details of 8 additional cases of complex biliary tract anomalies in thoraco-omphalopagus conjoined twins are reviewed. In all cases, the complex biliary anatomy has been associated with conjoined duodenum. In most cases the preoperative technetium 99m HIDA scan has been inconclusive or misleading. J Pediatr Surg 37:1716-1719. Copyright 2002, Elsevier Science (USA). All rights reserved.

Anatomical variations of the extrahepatic biliary tree: Review of the world literature

The anatomy facing a surgeon during cholecystectomy involves complex relationships between the hepatic artery, extrahepatic biliary tree, and gallbladder. A sound knowledge of the normal anatomy of the extrahepatic biliary tract is thus essential in the prevention of operative injury to it. Equally important, however, is an understanding of congenital variation of biliary and vascular anatomy, as the literature abounds with reports of specific anatomical variations, and their operative implications. This article reviews the world literature on congenital variation of extrahepatic biliary anatomy.

Mirizzi's syndrome: diagnostic and surgical considerations in 25 patients

Mirizzi's syndrome is a rare complication of long-standing cholelithiasis. Many surgical approaches of varying complexity have been advocated for treatment. However, the distorted extrahepatic biliary anatomy continues to be threatening, with a high risk of biliary complications. Presented here is a series of 25 patients with Mirizzi's syndrome who were treated at the Dokuz Eylul University Hospital since 1985. Type I lesion (without cholecystocholedochal fistula) was encountered in 11 patients, while the remaining 14 had type II lesions (with cholecystocholedochal fistula). Preoperative diagnoses were made in 14 of the 25 patients (56%). Follow-up in 17 patients ranged from 1 to 96 months (mean, 40 months). Unfortunately, the remaining 8 patients were lost to follow-up after discharge. The morbidity rate in our series was 32%, while no mortality was encountered. During long-term follow-up, no biliary stricture was diagnosed. Following an uneventful postoperative course, all of our patients are symptom-free and doing well, with normal liver function. We conclude that partial cholecystectomy alone is a safe and sound surgical approach for the treatment of type I lesions. For type II lesions, depending on the size of the fistula, either primary closure over a T-tube, or bilio-digestive anastomosis, preferably Roux-en-Y, can be an appropriate treatment modality, with a low morbidity rate.

The Importance of Extrahepatic Biliary Anatomy in Preventing Complications at Laparoscopic Cholecystectomy

Major biliary complications of laparoscopic cholecystectomy may be prevented by an understanding of extrahepatic biliary ductal and arterial anatomic relationships. The common patterns of anatomic variations important to the surgeon performing laparoscopic cholecystectomy are reviewed with respect to recently reported biliary injury during this procedure. Recommendations for delineating biliary anatomy and avoiding laparoscopic complications are reviewed.

Exposure, dissection, and laser versus electrosurgery in laparoscopic cholecystectomy

The technical complications of laparoscopic cholecystectomy occur while creating the pneumoperitoneum, placing trocars, obtaining exposure, and performing the initial dissection of the cystic duct and artery. The errors most feared are intestinal injury, vascular injury, and common bile duct injury. Bile duct injury usually results from the misinterpretation of the extrahepatic biliary anatomy. Confusion is most likely if the gallbladder infundibulum is pushed superiorly and medially, pulling the common bile duct out from behind the duodenum and into line with the cystic duct and gallbladder. Other dissection errors resulting in bile duct injury include the failure to begin dissection on the gallbladder, routine dissection of the cystic duct all the way to the common bile duct, failure to identify anomalies of the cystic and hepatic ducts, failure to open all folds of the gallbladder infundibulum, and entrapment of a narrow common bile duct by a cystic duct clip "slid" too far proximally. Proper dissection strategy includes posterolateral traction on the gallbladder infundibulum and initiation of dissection at the most medial point where the gallbladder is clearly seen. Pedunculation of the gallbladder will reveal most ductal anomalies but should be supplemented with routine digital fluoroscopic cholangiography. The controversy over optimal sources for thermal dissection of the gallbladder has largely been resolved. Electrosurgical dissection is a more rapid, hemostatic, and economical dissection.