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INDOCYANINE GREEN FLUOROESCENCE CHOLANGIOGRAPHY DURING LAPAROSCOPIC CHOLECYSTECTOMY

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.

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