Chapter 3 Consecutive patients (male and female) aged 18 years and above, scheduled for elective laparoscopic cholecystectomy (i.e. for cholecystolithiasis, cholecystitis) were eligible for inclusion in this study. Patients were excluded in case of liver or renal insufficiency, known iodine or ICG hypersensitivity and pregnancy. Laparoscopic fluorescence imaging system A newly developed laparoscopic fluorescence imaging system by Karl Storz (including a plasma light guide and 30‐degree 10‐mm laparoscope applicable for white light (WL), autofluorescence and ICG‐imaging) was used for intraoperative conventional imaging (WL mode) and real‐time fluorescence imaging (ICG mode). The system is equipped with a foot pedal, allowing the surgeon to easily switch from WL mode to ICG mode, and back. Because of the instantaneous changing of images and the stable position of the laparoscope, anatomical orientation can be maintained. Direct overlay of the fluorescence image on the WL anatomical image is not yet possible with the current system. Indocyanine green administration 1 ml of ICG (2.5mg/ml Infracyanine®; SERB, France) was injected intravenously directly after induction of anesthesia, in order to obtain intraoperative fluorescence illumination of the biliary tree. Infracyanine is an iodine‐free preparation of ICG. Fluorescence cholangiography during laparoscopic cholecystectomy The surgical procedure was performed according to the Dutch Guidelines and Best Practice for laparoscopic cholecystectomy14, which is based on the so‐called critical view of safety (CVS) technique – in essence the ‘surgical dissection’ of Calot’s triangle – as first described by Strasberg in 199515 and recommended by the Society of American Gastrointestinal and Endoscopic Surgeons16. Initial NIRFC was conducted at the first view of the liver hilum. Subsequently, fluorescence imaging was obtained every 5‐10 minutes until the CVS was established by the surgeon. See also Figure 3.1 for a flowchart of the study procedures. Image recording and data collection Intraoperatively the researcher systematically registered on a form whether the localization of specific relevant biliary structures (e.g. common bile duct, cystic duct, cystic artery) could be identified at set time points, comparing the WL camera mode to ICG mode. For agreement on the identification of the aforementioned structures the 40
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