Fluorescence cholangiography during laparoscopic cholecystectomy 39 Introduction Laparoscopic cholecystectomy (LC) is one of the most commonly performed laparoscopic procedures in gastrointestinal surgery. Bile duct injury during this procedure is rare but constitutes a serious complication (0.3‐0.7%)1‐4. Misidentification of the extra‐hepatic bile duct anatomy during laparoscopic cholecystectomy is the main cause of bile duct injury5. Intraoperative cholangiography has been advised to reduce the risk of bile duct injury1,6. However, this radiological imaging of the biliary tree is only used selectively, as the process takes time, radiation exposure is involved and additional equipment and manpower for the procedure are required. Moreover, worldwide consensus about implementation of intraoperative cholangiography is still lacking7. Near‐infrared fluorescence cholangiography (NIRFC) with preoperative intravenous injection of indocyanine green (ICG) is a promising new technique for easier intraoperative recognition of the biliary anatomy. It may help improve the outcome of laparoscopic cholecystectomy6,8. ICG is cleared quickly and exclusively by the liver after intravenous administration. Neither radiological support nor additional intervention, such as opening the biliary tree, is required. Intraoperative fluorescence imaging using ICG is not only used during gallbladder surgery, but also in other clinical fields, including sentinel node targeting in colorectal, breast, cervical and vulvar cancer surgery9‐12. Several fluorescence imaging systems for research purposes are available for both open10,13 and laparoscopic surgery9. The primary objective of this study was to test a newly developed laparoscopic fluorescence imaging system (Karl Storz GmbH & Co. KG, Tuttlingen, Germany) during elective laparoscopic cholecystectomy. Secondary goal was to assess whether earlier identification of the biliary anatomy could be obtained. Materials and methods Study procedures were conducted between December 2011 and May 2012 at the department of Surgery of Maastricht University Medical Center (MUMC, Maastricht, The Netherlands). All laparoscopic procedures were conducted by a surgical resident, assisted by a surgeon who had performed at least 150 laparoscopic cholecystectomies. The medical ethics committee of MUMC approved this study. The NIRFC‐LC study was registered in the Netherlands National Trial Register: registration number NTR3211 (http://www.trialregister.nl/trialreg/ admin/rctview.asp? TC=3211).
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