Fluorescence image guided cholangiography in a patient with grade II acute cholecystitis: case report

Laparoscopic cholecystectomy (LC) is the standard treatment method in patients with acute cholecystitis (AC). In the case of AC, bile duct (BD) and vascular anatomy can be changed due to perivesical inflammation and/or infiltration in hepatoduodenal Līgament which can lead to bile duct injury (BDI) during the surgery. In order to ensure a better visualization of BD anatomy and perform safe LC an innovative technique called Fluorescence Image Guided Cholangiography (FIGC) has been introduced. Case report: A 63 year old woman was admitted to the surgical department with AC. The overall anamnesis was 3 days. Laboratory findings showed signs of prolonged inflammation - WBC 19400/mm3, CRP 112mg/dL, total bilirubin 6mg/dL, ALT 12U/L, and AST 10U/L. An ultrasound revealed a thickened gallbladder wall 7 mm, common bile duct 6 mm. Conservative treatment was not effective. 48 hours after the admission the patient was scheduled for an emergency LC and FIGC. To avoid strong liver background and visualize extrahepatic bile ducts(EHBD) indocyanine green 12.5 mg was administered I/V 12 hours before the surgery. The operation time was 50 min and FIGC took 2 min which was performed both before and after maintaining Critical view of safety (CVS) principle in order to visualize the EHBD, thus decreasing the risk of BDI. The visualization was assessed according to an adapted Likert scale, Helpful score and Disturbed score. Visualization of EHBD, 1.before dissection: Cystic duct (CD)- good, Common bile duct(CBD)–good, Common hepatic duct(CHD)–fair, CD and CBD confluence-fair; 2.after dissection: CD-excellent, CBD-excellent, CHD-good, CD and CBD confluence-good. The postoperative course was uneventful and the patient was discharged on the fourth day. FIGC is a safe and effective method for better visualization of EHBD, even more it allows the surgeon to be more confident in situations when it is difficult to clearly understand biliary anatomy.