Surgical Endoscopy

, Volume 27, Issue 12, pp 4511–4517 | Cite as

Combined vascular and biliary fluorescence imaging in laparoscopic cholecystectomy

  • Rutger M. Schols
  • Nicole D. Bouvy
  • Ronald M. van Dam
  • Ad A. M. Masclee
  • Cornelis H. C. Dejong
  • Laurents P. S. Stassen
Article

Abstract

Background

Bile duct injury in patients undergoing laparoscopic cholecystectomy is a rare but serious complication. Concomitant vascular injury worsens the outcome of bile duct injury repair. Near-infrared fluorescence imaging using indocyanine green (ICG) is a promising, innovative, and noninvasive method for the intraoperative identification of biliary and vascular anatomy during cholecystectomy. This study assessed the practical application of combined vascular and biliary fluorescence imaging in laparoscopic gallbladder surgery for early biliary tract delineation and arterial anatomy confirmation.

Methods

Patients undergoing elective laparoscopic cholecystectomy were enrolled in this prospective, single-institutional study. To delineate the major bile ducts and arteries, a dedicated laparoscope, offering both conventional and fluorescence imaging, was used. ICG (2.5 mg) was administered intravenously immediately after induction of anesthesia and in half of the patients repeated at establishment of critical view of safety for concomitant arterial imaging. During dissection of the base of the gallbladder and the cystic duct, the extrahepatic bile ducts were visualized. Intraoperative recognition of the biliary structures was registered at set time points, as well as visualization of the cystic artery after repeat ICG administration.

Results

Thirty patients were included. ICG was visible in the liver and bile ducts within 20 minutes after injection and remained up to approximately 2 h, using the ICG-filter of the laparoscope. In most cases, the common bile duct (83 %) and cystic duct (97 %) could be identified significantly earlier than with conventional camera mode. In 13 of 15 patients (87 %), confirmation of the cystic artery was obtained successfully after repeat ICG injection. No per- or postoperative complications occurred as a consequence of ICG use.

Conclusion

Biliary and vascular fluorescence imaging in laparoscopic cholecystectomy is easily applicable in clinical practice, can be helpful for earlier visualization of the biliary tree, and is useful for the confirmation of the arterial anatomy.

Keywords

Laparoscopic cholecystectomy Critical view of safety Near-infrared fluorescence imaging Indocyanine green Bile duct and vasculobiliary injury 

Abbreviations

ICG

Indocyanine green

CVS

Critical view of safety

Notes

Acknowledgments

The authors thank Karl Storz GmbH & Co. KG (Tuttlingen, Germany) for providing the laparoscopic fluorescence imaging system and for technical assistance during the study. Furthermore, they acknowledge the surgeons and resident surgeons who performed the laparoscopic cholecystectomies in this study, and the patients who gave consent to participate in the study.

Disclosures

R.M. Schols, N.D. Bouvy, R.M. van Dam, A.A.M. Masclee, C.H.C. Dejong, and L.P.S. Stassen have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    Flum DR, Dellinger EP, Cheadle A, Chan L, Koepsell T (2003) Intraoperative cholangiography and risk of common bile duct injury during cholecystectomy. JAMA 289:1639–1644PubMedCrossRefGoogle Scholar
  2. 2.
    Fletcher DR, Hobbs MS, Tan P, Valinsky LJ, Hockey RL, Pikora TJ, Knuiman MW, Sheiner HJ, Edis A (1999) Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population-based study. Ann Surg 229:449–457PubMedCrossRefGoogle Scholar
  3. 3.
    Nuzzo G, Giuliante F, Giovannini I, Ardito F, D’Acapito F, Vellone M, Murazio M, Capelli G (2005) Bile duct injury during laparoscopic cholecystectomy: results of an Italian national survey on 56 591 cholecystectomies. Arch Surg 140:986–992PubMedCrossRefGoogle Scholar
  4. 4.
    Waage A, Nilsson M (2006) Iatrogenic bile duct injury: a population-based study of 152 776 cholecystectomies in the Swedish Inpatient Registry. Arch Surg 141:1207–1213PubMedCrossRefGoogle Scholar
  5. 5.
    Way LW, Stewart L, Gantert W, Liu K, Lee CM, Whang K, Hunter JG (2003) Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg 237:460–469PubMedGoogle Scholar
  6. 6.
    Sarno G, Al-Sarira AA, Ghaneh P, Fenwick SW, Malik HZ, Poston GJ (2012) Cholecystectomy-related bile duct and vasculobiliary injuries. Br J Surg 99:1129–1136PubMedCrossRefGoogle Scholar
  7. 7.
    Strasberg SM, Hertl M, Soper NJ (1995) An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 180:101–125PubMedGoogle Scholar
  8. 8.
    Kuwada T (2005) Highlights of the society of American gastrointestinal and endoscopic surgeons 2005, Annual Meeting April 13–16, 2005; Ft Lauderdale, Florida. Medscape General Surgery: Conference reports. http://wwwmedscapecom/viewarticle/506432. Accessed 14 Feb 2013
  9. 9.
    Agarwal BB (2009) Patient safety in laparoscopic cholecystectomy. Arch Surg 144:979PubMedCrossRefGoogle Scholar
  10. 10.
    Buddingh KT, Nieuwenhuijs VB, van Buuren L, Hulscher JB, de Jong JS, van Dam GM (2011) Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions. Surg Endosc 25:2449–2461PubMedCrossRefGoogle Scholar
  11. 11.
    Schols RM, Bouvy ND, Masclee AA, van Dam RM, Dejong CH, Stassen LP (2012) Fluorescence cholangiography during laparoscopic cholecystectomy: a feasibility study on early biliary tract delineation. Surg Endosc 27(5):1530–1536PubMedCrossRefGoogle Scholar
  12. 12.
    Lange JF, Stassen LPS (2006) Best practice in verband met de techniek van laparoscopische cholecystectomie (critical view of safety [CVS] in 7 stappen). Werkgroep Endoscopische Chirurgie van de Nederlandse vereniging voor Heelkunde. http://wwwheelkundenl/uploads/_6/re/_6reZZkgrYUAuCG6uvcN-A/richtlijn_galsteenpdf. Accessed 14 Feb 2013
  13. 13.
    Tagaya N, Shimoda M, Kato M, Nakagawa A, Abe A, Iwasaki Y, Oishi H, Shirotani N, Kubota K (2010) Intraoperative exploration of biliary anatomy using fluorescence imaging of indocyanine green in experimental and clinical cholecystectomies. J Hepatobiliary Pancreat Sci 17:595–600PubMedCrossRefGoogle Scholar
  14. 14.
    Ishizawa T, Bandai Y, Ijichi M, Kaneko J, Hasegawa K, Kokudo N (2010) Fluorescent cholangiography illuminating the biliary tree during laparoscopic cholecystectomy. Br J Surg 97:1369–1377PubMedCrossRefGoogle Scholar
  15. 15.
    Ishizawa T, Kaneko J, Inoue Y, Takemura N, Seyama Y, Aoki T, Beck Y, Sugawara Y, Hasegawa K, Harada N, Ijichi M, Kusaka K, Shibasaki M, Bandai Y, Kokudo N (2011) Application of fluorescent cholangiography to single-incision laparoscopic cholecystectomy. Surg Endosc 25:2631–2636PubMedCrossRefGoogle Scholar
  16. 16.
    Aoki T, Murakami M, Yasuda D, Shimizu Y, Kusano T, Matsuda K, Niiya T, Kato H, Murai N, Otsuka K, Kusano M, Kato T (2010) Intraoperative fluorescent imaging using indocyanine green for liver mapping and cholangiography. J Hepatobiliary Pancreat Sci 17:590–594PubMedCrossRefGoogle Scholar
  17. 17.
    Spinoglio G, Priora F, Bianchi PP, Lucido FS, Licciardello A, Maglione V, Grosso F, Quarati R, Ravazzoni F, Lenti LM (2013) Real-time near-infrared (NIR) fluorescent cholangiography in single-site robotic cholecystectomy (SSRC): a single-institutional prospective study. Surg Endosc 27(6):2156–2162PubMedCrossRefGoogle Scholar
  18. 18.
    Buchs NC, Hagen ME, Pugin F, Volonte F, Bucher P, Schiffer E, Morel P (2012) Intra-operative fluorescent cholangiography using indocyanine green during robotic single site cholecystectomy. Int J Med Robot 8:436–440PubMedCrossRefGoogle Scholar
  19. 19.
    Ashitate Y, Stockdale A, Choi HS, Laurence RG, Frangioni JV (2012) Real-time simultaneous near-infrared fluorescence imaging of bile duct and arterial anatomy. J Surg Res 176(1):7–13PubMedCrossRefGoogle Scholar
  20. 20.
    Mitsuhashi N, Kimura F, Shimizu H, Imamaki M, Yoshidome H, Ohtsuka M, Kato A, Yoshitomi H, Nozawa S, Furukawa K, Takeuchi D, Takayashiki T, Suda K, Igarashi T, Miyazaki M (2008) Usefulness of intraoperative fluorescence imaging to evaluate local anatomy in hepatobiliary surgery. J Hepatobiliary Pancreat Surg 15:508–514PubMedCrossRefGoogle Scholar
  21. 21.
    Kaneko J, Ishizawa T, Masuda K, Kawaguchi Y, Aoki T, Sakamoto Y, Hasegawa K, Sugawara Y, Kokudo N (2012) Indocyanine green reinjection technique for use in fluorescent angiography concomitant with cholangiography during laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 22:341–344PubMedCrossRefGoogle Scholar
  22. 22.
    Pulitano C, Parks RW, Ireland H, Wigmore SJ, Garden OJ (2011) Impact of concomitant arterial injury on the outcome of laparoscopic bile duct injury. Am J Surg 201:238–244PubMedCrossRefGoogle Scholar
  23. 23.
    Schmidt SC, Langrehr JM, Raakow R, Klupp J, Steinmuller T, Neuhaus P (2002) Right hepatic lobectomy for recurrent cholangitis after combined bile duct and right hepatic artery injury during laparoscopic cholecystectomy: a report of two cases. Langenbecks Arch Surg 387:183–187PubMedCrossRefGoogle Scholar
  24. 24.
    Strasberg SM, Helton WS (2011) An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy. HPB (Oxford) 13:1–14CrossRefGoogle Scholar
  25. 25.
    Schols RM, Bouvy ND, van Dam RM, Stassen LP (2013) Advanced intraoperative imaging methods for laparoscopic anatomy navigation: an overview. Surg Endosc 27(6):1851–1859PubMedCrossRefGoogle Scholar
  26. 26.
    Ford JA, Soop M, Du J, Loveday BP, Rodgers M (2012) Systematic review of intraoperative cholangiography in cholecystectomy. Br J Surg 99:160–167PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Rutger M. Schols
    • 1
    • 3
  • Nicole D. Bouvy
    • 1
    • 3
  • Ronald M. van Dam
    • 1
    • 3
  • Ad A. M. Masclee
    • 2
    • 3
  • Cornelis H. C. Dejong
    • 1
    • 3
  • Laurents P. S. Stassen
    • 1
    • 3
  1. 1.Department of SurgeryMaastricht University Medical CenterMaastrichtThe Netherlands
  2. 2.Department of Gastroenterology and HepatologyMaastricht University Medical CenterMaastrichtThe Netherlands
  3. 3.NUTRIM School for Nutrition, Toxicology and MetabolismMaastricht UniversityMaastrichtThe Netherlands

Personalised recommendations