Identification of biliovascular anatomy by using indocyanine green fluorescent cholangiography in patients with acute cholecystitis: First experience in single institution

Background: Iatrogenic biliovascular injuries after laparoscopic cholecystectomy (LC) are serious complications with an incidence of 0.3-1.5%. Achievement of "critical view of safety" is advocated but it is not always possible in patients with acute cholecystitis. Near-infrared fluorescence cholangiography (FCHA) using Indocyanine green (ICG) is non-invasive intraoperative technique for visualization of biliary tract anatomy by using fluorescence effect. Objective(s): To share first experience by application of FCHA during LC for acute cholecystitis. Methods and materials: Urgently admitted surgical patients with long standing anamnesis (>72 hours) for acute cholecystitis were prospectively included between June 2017 to August 2018 in study. Acute cholecystitis was graded in accordance to Tokyo 2018 guidelines. All patients underwent LC with FCHA. 25mg of ICG was diluted with 20mL of normal saline and 10mL of the solution was intravenously administered at least 2 hours before surgery. 10mL were injected intraoperatively for detection of cystic artery. Result(s): Overall 9 patients with average age of 56 years (29-82) underwent urgent LC. Average time from first symptoms till surgery was 4 (3-11) days. 5 (56%) patients had moderate and 4 (44%) mild acute cholecystitis. FCHA before dissection of Calot's triangle allowed successfully visualise the cystic duct in all patients and the cystic duct/common bile duct junction in 7 (78%). Identification of common hepatic and common bile duct was successful in 5 (56%) of patients. Cystic artery was clearly identified in 7 patients. Average operation time was 54 (40-80) minutes. There were no bile duct injuries or need for conversion to open surgery. In 78% FCHA improved visualization of biliary anatomy. Postoperative course was uncomplicated, and patients were discharged on average 2 days after surgery. Conclusion(s): Fluorescent cholangiography could be safely used for better visualization of bile duct anatomy before dissection of Calot's triangle in patients with acute cholecystitis undergoing urgent LC.Copyright © 2020