from the APSA 2017 Annual Meeting proceedings
INDOCYANINE GREEN FLUOROESCENCE CHOLANGIOGRAPHY DURING LAPAROSCOPIC CHOLECYSTECTOMY
Claire Graves, MD1, Olajire Idowu, MD2, Christopher R. Newton, MD2, Sunghoon Kim, MD2.
1UCSF Benioff Children’s Hospital, San Francisco, CA, USA, 2UCSF Benioff Children’s Hospital, Oakland, CA, USA.
Purpose: Laparoscopic cholecystectomy is a common procedure performed by pediatric surgeons. Though rare, with an incidence of approximately 0.4% in the pediatric population, bile duct injury is a serious complication often requiring complex reconstruction. Aberrant or distorted anatomy often contributes to biliary injuries, and accurate identification of the anatomy is paramount. Indocyanine Green (ICG) fluorescence, visualized with near-infrared (NIR) imaging, improves visualization and provides detailed anatomical mapping of the biliary structures. Though increasingly used in adults via intravenous administration, this video demonstrates the first human use of ICG injected directly into the gallbladder during laparoscopic cholecystectomy.
Methods: Our patient is a 17-year-old female who presented with biliary colic. A 0.25mg/ml ICG solution is prepared on the surgical backtable. A laparoscopic tower with NIR imaging capability is used. After traditional 4-port access is obtained, a needle- tip cholangiogram catheter is used to puncture the infundibulum of the gallbladder. 9ml of bile is drained and mixed with 1ml of the ICG solution to create a 0.025 mg/ml ICG and bile solution. The ICG and bile solution is then re-injected into the gallbladder. The pre-mixed solution fluoresces under NIR light immediately upon injection with no lag time, quickly filling the gallbladder and extrahepatic biliary system.
Results: ICG fluorescence aids significantly in the visualization of the gallbladder, cystic duct and common bile duct. When dissecting the gallbladder from the liver bed, this technique shows a well-defined plane and can be used to identify accessory bile ducts.
Conclusion: We demonstrate the first case of direct administration of ICG into the gallbladder during laparoscopic cholecystectomy. This technique is safe, avoids radiation and can be easily adopted by surgeons to improve visualization of the biliary tree.