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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_585_Библиотеки_им_академика_М_И_Перельмана.pdf
154
S. Bao et al.
a
Fig. 6.13 Left hemi-hepatectomy simulated operation (a) Open the
liver and dilate the bile duct; (b) Remove intrahepatic bile duct stones;
(c) Cut off the hepatic vein; (d) Suture the broken end of hepatic vein;
(e) Continue to cut the liver parenchyma; (f) Cut off the left portal vein;
(g) Suture the stump of the left portal vein; (h) There was no residual
b
stone in the right half of the liver and its ducts; (i) Residual calculi in the
intrahepatic bile duct can be seen after the left liver and its ducts are
transparent; (j) Suture the liver cross-section; (k) The remaining right
liver was examined again after transparency, and no residual stones
were found
6 Virtual Surgical Instruments andSurgical Simulation
155
c
d
Fig. 6.13 (continued)
156
S. Bao et al.
e
Fig. 6.13 (continued)
f
6 Virtual Surgical Instruments andSurgical Simulation
157
g
h
Fig. 6.13 (continued)
158
S. Bao et al.
i
Fig. 6.13 (continued)
j
6 Virtual Surgical Instruments andSurgical Simulation
Fig. 6.13 (continued)
159
k
tive selection of the optimal surgical path, reduction of
surgical damage including to the adjacent tissue, the improvement of the positioning accuracy, the performance of the
complex surgery, and improved success rate of surgery. With
the continuous advancement of computer and medical technology, as well as the further research and development of
medical 3D image visualization reconstruction software and
virtual surgery systems, this advanced multidisciplinary
technology will play a more signicant role in clinical application, and become an indispensable tool assisting liver surgeons (Resource 6.1).
References
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org/10.1097/00000658- 200102000- 00011.
Application ofIndocyanine Green
Fluorescent Imaging inBiliary Surgery
ChihuaFang andWenZhu
7
7.1 Introduction
Molecular imaging (MI) is a comprehensive interdisciplinary subject that is the product of the combination of medical
imaging technology and modern molecular biology. It
involves the qualitative and quantitative study of organisms
invivo at the cellular and molecular levels through imaging
technology and methods. Through MI, various
pathophysiological processes in the body at the cellular or
subcellular levels can be reected and identied. Compared
with the current clinical imaging studies of the human form
from the morphological and structural aspects, molecular
imaging focuses on revealing the occurrence and development process of diseases at the level of biochemical and
intracellular pathways. Optical imaging, as an essential component and living force of molecular imaging, combines
high sensitivity with no ionizing radiation. It can detect the
optical signals emitted by endogenous or exogenous contrast
agents and present to the observer the coding information of
the biochemistry process invivo carried by the signal.
In recent years, with continuous expansion of molecular
uorescence imaging technology in surgical applications,
indocyanine green (ICG), as a tracer or contrast agent, has
shown considerable application prospects. This chapter
introduces the application of ICG uorescent imaging in the
accurate diagnosis and management of biliary surgery in
recent years.
ICG is a near-infrared uorescent dye, which can be
excited at wavelengths of 750–810nm and emits uorescence
that peaks at about 840 nm (Jonak et al. 2011; Landsman
et al. 1976). In this spectral region, the near-infrared light
emits a uorescent signal with a penetration depth of
5–10mm due to the low absorption of hemoglobin or water;
moreover, this region can be detected by an imaging device
that is sensitive to infrared light and has a suitable lter
C. Fang (*) · W. Zhu
Zhujiang Hospital, Southern Medical University,
Guangzhou, China
(Morita etal. 2013). Notably, ICG has been approved by the
US Food and Drug Administration (USFDA) and the China
Food and Drug Administration (CFDA) for human use. As a
medical imaging medium, it has been used in humans for
over 50years. Because the near-infrared light has more substantial penetrating power than other light bands, ICG has a
critical advantage as the optical imaging medium of human
body tissue. In recent years, there has been an explosion of
interest in the application of ICG uorescent imaging technology in surgery; however, it can only be used as a tracer or
contrast agent. The application of ICG uorescence imaging
in hepatobiliary surgery has been rapidly expanding since
Ishizawa rst reported the use of ICG uorescent imaging in
hepatocellular surgery (Ishizawa etal. 2009).
Congenital anatomical variations of the extrahepatic biliary system are common. The surgeon’s misidentication or
improper management of these variations may lead to disastrous adverse events, such as bile duct injury. Therefore,
variations in the anatomy of the bile duct should be recognized in each operation. Near-infrared uorescence imaging
has received widespread attention. As ICG is introduced into
the human body via intravenous administration, it can be
selectively absorbed by hepatocytes and excreted into bile in
a free form (Osayi etal. 2015). It will pass into the common
bile duct and gallbladder through each level of the bile duct,
and nally be discharged into the duodenum. Light is applied
around the peak absorption wavelengths (750–810 nm)
exciting the ICG molecules which then return to their unexcited state by emitting light around 850nm. Then, the emitted light signal is captured by the imaging system and
processed to form the uorescence image of extrahepatic
bile ducts. Surgeons can grasp the intraoperative conditions
in real time and provide substantive guidance and assistance
for operation.
At present, preoperative medical imaging techniques for
the biliary tract mainly include MRCP, CT, and direct cholangiography. Through these imaging techniques, surgeons
can preliminarily understand the anatomy and pathology of
the biliary tract and determine the operation method.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021
C. Fang, W. Y. Lau (eds.), Biliary Tract Surgery, https://doi.org/10.1007/978-981-33-6769-2_7
161
162
C. Fang and W. Zhu
However, it is difcult to identify the bile ducts, to decrease
the risk of bile duct injury intraoperatively, when there are
adhesion, inammation, and reoperation. Intraoperative
cholangiography has been considered as a reliable prophylactic technique; however, it has not been supported by costeffectiveness analysis. The question about selective
intraoperative cholangiography is that it lacks clear implementation standards, and also, the biliary tract injury may
have already occurred when surgeons are faced with difculties in preparing for cholangiography. Intraoperative cholangiography also has the following drawbacks:
• It is an invasive examination, which requires puncture of
the cystic duct or injection of contrast medium via the end
of the cystic duct.
• The operation is complicated, which requires highly qualied radiology technicians to operate, and there is a risk
of radiation exposure.
• Iodine may lead to the risk of an allergic reaction.
According to the statistics, allergic reactions to highosmolar ionic contrast occur between 4% and 12%, while
such reactions present in about 0.7% to 3% of patients
with low-osmolar nonionic contrast (Trcka etal. 2008;
Lieberman and Seigle 1999). It is estimated that severe
anaphylaxis occurs in 0.1% to 0.4% with ionic contrast
agents and 0.02% to 0.04% with nonionic contrast agents
(Trcka etal. 2008; Caro etal. 1991).
• There is a risk of bile duct injury. Severe inammation of
the cystic duct and common bile duct is a precipitating
event that will result in rupture of the cystic duct or
perforation of the common bile duct when a catheter is
inserted into the common bile duct.
• There is a certain failure rate of angiography.
By contrast, the prominent advantages of ICG uores-
cence imaging are obvious: real-time imaging with high
specicity and sensitivity; non-invasiveness; cost-effective;
safety (radiation-free); ease of use, minimal learning curve
(Pesce etal. 2015).
7.2 ICG Fluorescence Imaging
inPreventing Bile Duct Injury
inLaparoscopic Cholecystectomy
Laparoscopic cholecystectomy (LC) has been considered the
gold standard for gallbladder diseases. As a classic minimally
invasive surgical technique, LC has the advantages of less
pain, shorter hospitalization time, and faster recovery.
However, as LC was gaining popularity, the tendency of bile
duct injury increased. Statistical analyses show that the
incidence of bile duct injury in LC ranges between 0.3% and
1.4% (Abbasoğlu etal. 2016). The main manifestations of
bile duct injuries include bile duct stricture, biliary leakage,
and transection or clipping of the bile duct. Though some of
the bile duct injuries are attributed to the “learning curve” in
the theatre of operation, the primary cause of these injuries is
misinterpretation of biliary anatomy, which accounts for
71%–97% (Way et al. 2003). To avoid such tragic errors,
surgeons have been developing and introducing techniques
that can directly display the location and course of
extrahepatic bile ducts. Intraoperative cholangiography has
been considered as a reliable tool for preventing bile duct
injury during surgery. However, it is not recommended for
routine use due to certain limitations in its implementation.
In recent years, various intraoperative navigation techniques
such as ICG-mediated near-infrared uorescence
cholangiography, which can display the extrahepatic biliary
system in real-time, have been widely used in surgery (Dip
etal. 2014). Because of the uorescent property of ICG and
its biliary excretion properties, the emitted light intensity
within the bile duct allows real-time enhanced visualization
of the course of the extrahepatic bile duct, which can greatly
increase the safety of the procedure by minimizing the
incidence of intraoperative inadvertent bile duct injury.
Normal anatomy of the biliary tract can be altered due to
anatomic variations of extrahepatic bile ducts or local lesions
in the Calot’s triangle. Variations of the hepatobiliary
vasculature include the cystic duct, right hepatic duct,
common bile duct, cystic artery, and right hepatic artery.
85% of the aberrant anatomy is observed within Calot’s
triangle (Sanjay etal. 2012). Anatomical variation is reported
as a contributing risk factor for bile duct injury in LC.The
main reasons leading to misinterpretation are as follows:
• The operating surgeon is not familiar with surgical anatomy under laparoscope and is not careful in identifying
the anatomical area of the Calot’s triangle.
• Improper gallbladder traction. Excessive or insufcient
traction will lead to changes in the relationship between
the “tree tubes,” resulting in bile duct misidentication.
With an incarcerated gallbladder neck stone and thin
common bile duct, the excessive upward traction of the
gallbladder may lead to the displacement of the common
bile duct and bile duct injury.
• The change of anatomical position under laparoscope
after the rotation of the lens may result in misidentication.
• Anatomical and pathological factors: Congenital anatomical variation or displacement of the bile duct due to
repeated inammation and adhesion in the Calot’s triangle may lead to unclear dissection.
Therefore, the key to prevent extrahepatic biliary injuries
is to detect the anatomical variations of the extrahepatic bile
ducts and identify the position of the bile ducts (Fig.7.1).
Preoperative MRCP and intraoperative cholangiography
7 Application ofIndocyanine Green Fluorescent Imaging inBiliary Surgery
Fig. 7.1 ICG uorescence
cholangiography shows cystic
duct, common bile duct, and
common liver duct. The cystic
duct enters the common bile
duct on the left
Fig. 7.2 ICG uorescence
imaging of extrahepatic
biliary ducts under SPY
uorescence mode showed
clear differentiation of cystic
duct, common bile duct, and
left/right hepatic duct
163
can better display the biliary anatomy and aid timely detection of biliary tract variations. Although MRCP can help
biliary surgeons to understand the anatomy of the biliary
tract sensitively before operation, it cannot be used as a realtime guide during operation. Studies showed that the use of
intraoperative direct cholangiography can reduce the risk of
bile duct injury from 0.58% to 0.39% (Flum etal. 2003).
However, the advantages of cholangiography in conventional surgery have been questioned. ICG near-infrared
molecular uorescence can better display the biliary tract
after intravenous injection. Due to its relatively poor penetration into surrounding tissues, it can enhance the display
of the extrahepatic biliary tract, especially the Calot’s triangle (Fig. 7.2). Through ICG uorescence imaging, the
anatomy and variations of the bile duct, cystic duct, common bile duct, and common hepatic duct can be observed.
After dissociating the tissues around the vasculature, the
anatomical structure of the extrahepatic bile duct can be
clearly developed by ICG near-infrared uorescence. At this
time, transection of the cystic duct is safer (Fig.7.3), which
provides real-time guidance for beginners or inexperienced
physicians. For patients whose normal anatomical structure
has changed signicantly after repeated biliary tract surgery
or whose anatomy is difcult to distinguish, ICG uorescence imaging can provide real-time intraoperative bile duct
imaging to help doctors locate the bile duct, avoid inadvertent injury, and guide surgical treatment in real time
(Figs.7.4 and 7.5).
164
Fig. 7.3 Before dissociating
the cystic duct, the course of
the cystic duct was
determined by ICG molecular
uorescence imaging, so as to
sever the cystic duct more
safely
Fig. 7.4 ICG uorescent
imaging of the extrahepatic
biliary tract helps to identify
the biliary system. No
uorescence development was
seen in the front pipe of the
electrocoagulation hook,
which was considered as a
thick gallbladder artery.
Fluorescent below is the
cystic duct, which helps the
doctor locate the bile duct and
avoid damage
C. Fang and W. Zhu
Fig. 7.5 The biliary tract
development of ICG
uorescence indicated a low
conuence between the cystic
duct and the common bile
duct, which could help avoid
intraoperative injury to the
common bile duct