Fluorescence cholangiography during laparoscopic cholecystectomy after on average of 23 minutes, whereas using WL camera mode this took on average of 31 minutes (P-value 0.0004). See also Table 3.2 for intraoperative registration. Using fluorescence cholangiography the CBD and CD could be clearly visualized and delineated before dissection of Calot’s triangle in 15/15 patients. See Figure 3.2A–3.2C for an example of the peroperative WL images and corresponding NIRFC images before and during the dissection of Calot’s triangle. In one patient a parallel course17 of the cystic duct and common hepatic duct was identified; see Figure 3.2B. Critical view of safety was obtained in a median 40 minutes after incision. We observed no prolonged preparation time before start of surgery and only a negligible extension of the operation time (1-2 minutes) due to the use of the NIRFC technique. As a preventive measure, in 3/15 patients the gall bladder was punctured and drained during surgery to facilitate manipulation; no major bile leakage occurred, and this did neither compromise fluorescence imaging of the biliary tract nor the postoperative course. Table 3.2 Intraoperative time registration Number of patients (n=15) 43 Time between ICGa injection and Time between introduction laparoscope and First NIRFC CDd CBDe CVSf Introduction laparoscope First NIRFCb NIRFC WLc NIRFC WL Median time in minutes range 19 12-35 33 19-67 15 5-47 23 5-47 31 9-54 22 5-65 32 9-65 40 12-70 P=0.0004* P=0.001* ICG = intravenous indocyanine green administration; NIRFC = near-infrared fluorescence cholangiography; WL = conventional white light imaging; CD = identification of cystic duct; CBD = identification of common bile duct; CVS = establishment of critical view of safety. * Significant difference (P<0.05) Fluorescence data analysis TBR of CD was 3.6 and TBR of CBD was 3.9 (28 minutes after ICG injection), as can be seen in Figure 3.2B. Figure 3.2C shows TBR of CD of 7.9 and TBR of CBD of 6.3 (36 minutes post-ICG injection). Mean TBR at establishment of CVS (median 59 minutes after ICG administration) amounted to 5.6 for CD and 6.8 for CBD. Per- and postoperative complications No per- or postoperative complications (e.g. no intra-abdominal bile leakage or gallstone spill) occurred. None of the patients developed any adverse reactions to the injected ICG.
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