Near-infrared cholangiography with intragallbladder indocyanine green injection in minimally invasive cholecystectomy

Abstract

Laparoscopic cholecystectomy (LC) remains one of the most commonly performed procedures in adult and paediatric populations. Despite the advances made in intraoperative biliary anatomy recognition, iatrogenic bile duct injuries during LC represent a fatal complication and consist an economic burden for healthcare systems. A series of methods have been proposed to prevent bile duct injury, among them the use of indocyanine green (ICG) fluorescence. The most commonly reported method of ICG injection is the intravenous administration, while literature is lacking studies investigating the direct intragallbladder ICG injection. This narrative mini-review aims to assess the potential applications, usefulness, and limitations of intragallbladder ICG fluorescence in LC. Authors screened the available international literature to identify the reports of intragallbladder ICG fluorescence imaging in minimally invasive cholecystectomy, as well as special issues regarding its use. Literature search retrieved four prospective cohort studies, three case-control studies, and one case report. In the three case-control studies selected, intragallbladder near-infrared cholangiography (NIRC) was compared with standard LC under white light, with intravenous administration of ICG for NIRC and with standard intraoperative cholangiography (IOC). In total, 133 patients reported in the literature have been administered intragallbladder ICG administration for biliary mapping during LC. Literature includes several reports of intragallbladder ICG administration, but a standardized technique has not been established yet. Published data suggest that NIRC with intragallbladder ICG injection is a promising method to achieve biliary mapping, overwhelming limitations of IOC including intervention and radiation exposure, as well as the high hepatic parenchyma signal and time interval needed in intravenous ICG fluorescence. Evidence-based guidelines on the role of intragallbladder ICG fluorescence in LC require the assessment of further studies and multicenter data collection into large registries.

Keywords: Minimally invasive cholecystectomy, Laparoscopic cholecystectomy, Biliary tract mapping, Indocyanine green, Near-infrared fluorescent cholangiography, Intracystic indocyanine green, Intragallbladder indocyanine green, Bile duct injury

Core Tip: Direct intragallbladder indocyanine green (ICG) administration is a scarcely reported technique of near-infrared fluorescence cholangiography during laparoscopic cholecystectomy. A series of advantages, such as high rates of biliary structure visualization, lower hepatic parenchyma background signal and intraoperative dye administration, render this option a feasible and promising alternative to the commonly used intravenous ICG fluorescent cholangiography. However, further studies are needed in order to standardize optimal aspects of this technique in clinical practice.