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Guidance in Cholecystectomy
RyanC.Broderick, DavidRenton, andSantiagoHorgan
Introduction
Laparoscopic cholecystectomy (LC) is widely accepted as the standard of care for cholecystectomy. It is currently the most commonly performed procedure performed by general sur­geons in the United States. Bile duct injuries in the era of lapa­roscopic cholecystectomy range from 0.03% to 0.5% [1–4]. While infrequent, they represent a signicant patient and healthcare burden when these injuries occur. Cost of treating bile duct injuries can be 4.5 to 26 times the cost of an uncom­plicated procedure with an average 32-day hospitalization and signicant mortality rate [5].
4
Supplementary Information The online version contains supplementary material available at
R. C. Broderick (*) · S. Horgan Division of Minimally Invasive Surgery, Department of Surgery, University of California San Diego, La Jolla, CA, USA e-mail: rbroderick@health.ucsd.edu; shorgan@health.ucsd.edu
D. Renton Center for Minimally Invasive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA e-mail: david.renton@osumc.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 N. Szoka et al. (eds.), The SAGES Manual of Fluorescence-Guided Surgery, https://doi.org/10.1007/978-3-031-40685-0_4
https://doi.org/10.1007/978- 3- 031- 40685- 0_4.
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R. C. Broderick et al.
Indocyanine green (ICG) dye is a water-soluble dye with spec­tral absorption at 800 nm. It has been described visualizing the biliary tree since 2008 [6]. When injected intravenously, ICG binds plasma proteins before being rapidly metabolized by hepatocytes and excreted exclusively into the bile; protein-bound ICG uo­resces green when illuminated with near-infrared (NIR) light [6–
9]. The excretion of ICG into the biliary tree peaks at 2–4h after
intravenous injection [10]. Dynamic, real-time NIR light capabil­ity is built-in to many modern laparoscopic and robotic cameras. As described elsewhere in this manual, there are also cameras designed to image ICG in open surgery. These cameras are able to toggle between white-light and NIR light with the push of a button, allowing real-time imaging without disrupting surgical workow, especially in the case of laparoscopic or robotic surgery (Figs.4.1,
4.2, and 4.3; video clip attached for video chapter). The technol-
ogy incorporates smoothly into the operation without increased need for stafng or additional supplies in the operative theater.
Through constant reassessment of the anatomy with NIR imaging, surgeons may continuously identify the position of criti­cal biliary structures; these structures are often identiable prior to dissection of peritoneal layer of the gallbladder, providing a safe dissection starting point as well as areas of critical impor­tance. FC offers the potential detailed anatomical mapping of extrahepatic biliary structures and can be a useful adjunct to the critical view of safety [6–14]. FC allows for surgeons to identify either normal anatomy or anatomic variation prior to dissection
Fig. 4.1 Top panel: white-light laparoscopic view of gallbladder during cho­lecystectomy. Bottom panel: “overlay mode” ICG view of same patient show­ing cystic duct and common bile duct junction
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Fig. 4.2 Top panel: white-light laparoscopic view of gallbladder during cho­lecystectomy prior to peritoneal dissection. Bottom panel: “gray mode” ICG view of same image showing cystic duct, common bile duct, and junction
Fig. 4.3 Use of uorescence cholangiography in robotic surgery. Left panel is traditional bright light view. Right panel is ICG mode highlighting cystic duct, CBD, and CD-CBD junction
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and during active dissection. In contrast, IOC can be time con­suming and involves exposure of the patient and ancillary staff to radiation, with associated increases in cost [15].
Literature Review
Ishizawa etal. described their laparoscopic experience with pre­operative ICG injection for cholangiography during cholecystec­tomy, demonstrating a 100% visualization of the cystic duct and 96% visualization of the common hepatic duct prior to any dissec­tion, which improved to 100% visualization of both structures with dissection [7]. Several other groups have demonstrated simi-
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Table 4.1 Fluorescence cholangiography in laparoscopic cholecystectomy in literature. Reported common bile duct injuries and level of evidence for each study
First author (year)
Ishizawa (2010) 52 0 0 – IV Boni (2015) 52 0 0 IV Dip (2015) 45 0 0 IV Osayi (2015) 82 0 0 IV van Dam
(2015) Dip (2016) 70 0 0 0 IV Dip (2019) 318 0 0 1 II Hiwatashi
(2018) Broderick
(2022)
Total patients
37 0 0 IV
65 0 0 7 IV
828 0 0 6 III
Bile duct injuries
Adverse reactions
R. C. Broderick et al.
Conversions to open
Level of evidence
lar ndings during laparoscopic cholecystectomy, as well as dur­ing robotic-assisted laparoscopic cholecystectomy, including in obese individuals [6–21]. With a growing body of literature, some surgeons have advocated for FC to become the standard of care in laparoscopic cholecystectomy in both elective and emergent cho­lecystectomy.
The highest level evidence conrming uorescent visualization of extrahepatic biliary anatomy was shown in two studies. Dip etal. in 2019 published a single-blind randomized controlled trial comparing FC (n=312) vs LC (n=318) demonstrating that FC was statistically superior in identifying extrahepatic biliary structures [13]. Bile duct injury was zero in FC and two patients in LC; operative times and other complications were not reported. Lim etal. performed a meta­analysis of seven studies comparing biliary anatomy visualization with IOC versus FC.Rates of extrahepatic biliary anatomy identica­tion included cystic duct, common bile duct, CD-CBD junction, and common hepatic duct. FC was safe and effective [14].
Tables 4.1 and 4.2 feature studies evaluating uorescence chol­angiography (FC) during cholecystectomy to evaluate common bile duct injury and operative times. The studies listed are mostly
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