Authors (including presenting author) :
Lai KM
Affiliation :
Hepatobiliary team, Department of Surgery, Tuen Mun Hospital
Introduction :
Bile duct injury is a severe complication in cholecystectomy. It has been shown that many cases of bile duct injury were due to poor visualization and misidentification of anatomical structures. Indocyanine Green (ICG) florescence cholangiography is a method to help surgeons in recognition of biliary structures during cholecystectomy. However, it is not adopted worldwide in standard cholecystectomy as the optimal dosage and timing of ICG injection are still under investigation and there is no consensus internationally. Previous studies revealed the use various dosage of ICG, ranged from 0.05mg/kg to 7.5mg regardless of body weight. Time of injection also vary from 20 hours before operation, to given just before operation or intra-operatively. (1)
A local single-center randomized controlled trial was published by She et al in 2022 (2) with the use of 3.5mg intravenous ICG 30 minutes before general anesthesia for emergency cholecystectomy. Cholangiography was graded A, B and C in comparison of contrast between biliary tract and liver (A: contrast of biliary tract stronger, B: biliary tract and liver similar, and C: contrast of liver stronger). The result found that majority (60.9%) of the quality of ICG cholangiography was suboptimal, ie. grade B/C, while only 39.1% was grade A.
Recently, it has been advocated the use of much diluted ICG as a higher dose might result in over-detection of adjacent structures, making the biliary tract more difficult to be distinguished from its surroundings.
(1) Lie H, Irawan A, Sudirman T, et al. Efficacy and Safety of Near-Infrared Florescence Cholangiography Using Indocyanine Green in Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A. 2023;33(5):434-446. doi:10.1089/lap.2022.0495
(2) She WH, Cheung TT, Chan MY, et al. Routine use of ICG to enhance operative safety in emergency laparoscopic chole- cystectomy: A randomized controlled trial. Surg Endosc 2022;36(6):4442–4451; doi: 10.1007/s00464-021-08795-2
Objectives :
This study aimed to investigate the efficacy and safety of a super-diluted intravenous dose, 0.025mg, given on induction of general anaesthesia, for ICG cholangiography in cholecystectomy.
Methodology :
From 19th December 2024 to 16th January 2025, ICG cholangiography was performed in all cholecystectomy in a hepatobiliary team in Tuen Mun Hospital. Apart from the use of fluorescence imaging system, cholecystectomy was performed as usual. All procedures were started with laparoscopic approach and would be converted to open surgery if necessary as clinically judged by the operating surgeons.
All procedures were performed by surgical fellow (with at least 7 years of surgical training); or performed by a higher surgical trainee (with at least 3 years of surgical training), who is supervised by a surgical fellow.
Three endoscopic fluorescence imaging systems were used. One was VISERA ELITE II 10mm IR Telescope (Olympus Corporation, Tokyo, Japan). Second one was HOPKINS RUBINA 30° NIR/ICG 10mm Fluorescence Imaging (Karl Storz SE, Tuttlingen, Germany). Third one was Stryker 10.0mm 30° AIM HD Autoclavable Laparoscope, 33cm (Stryker Corporation, Kalamazoo, Michigan, USA). Surgeons were allowed to freely switch between white-light color image and fluorescence image during the operation.
A vial of 25mg ICG as diluted into 0.025mg with normal saline and was injected intravenously on induction of general anaesthesia, followed by 5ml normal saline flush. No repeated dose of ICG was used. Intravenous antibiotics were given as usual.
Outcomes including grading of cholangiography (grade A/B/C), time to identify biliary structure (common bile duct & cystic duct), operation time, rate of conversion to open surgery, reasons for conversion, hospital stay, and bile duct injury were observed.
Result & Outcome :
Totally 8 patients underwent cholecystectomy in the study period. ICG cholangiography was performed in all patients. One of them were emergency cholecystectomy for acute cholecystectomy, while 7 of them were elective cholecystectomy. Indications for elective cholecystectomy included interval cholecystectomy for previous acute cholecystitis, common bile duct stone required endoscopic retrograde cholangiopancreatography, necrotizing pancreatitis and large gallbladder polyp.
6 out of 8 (75%) ICG cholangiography were grade A. 2 out of 8 (25%) ICG cholangiography were grade B. There was no grade C ICG cholangiography. Mean time to identify biliary structure was 35.6 (20-70) minutes. Mean operation time was 100.9 (65-164) minutes.
2 patients (25%) required laparoscopic converted to open cholecystectomy, due to dense peritoneal adhesion from previous laparotomy, and dense adhesion at Calot’s triangle, respectively. Mean hospital stay was 2.9 (1-6) days. There was no bile duct injury.
In conclusion, high quality ICG cholangiography can be safely performed in cholecystectomy with a single-shot intravenous 0.025mg ICG on induction of general anaesthesia.
