Chapter 4 Abstract Background Bile duct injury in patients undergoing laparoscopic cholecystectomy is a rare but serious complication. Concomitant vascular injury worsens the outcome of bile duct injury repair. Near‐infrared fluorescence imaging using indocyanine green (ICG) is a promising, innovative and noninvasive method for the intraoperative identification of biliary and vascular anatomy during cholecystectomy. This study aimed to assess the practical application of combined vascular and biliary fluorescence imaging in laparoscopic gallbladder surgery for early biliary tract delineation and arterial anatomy confirmation. Methods Patients undergoing elective laparoscopic cholecystectomy were enrolled in this prospective, single‐institutional study. To delineate the major bile ducts and arteries a dedicated laparoscope, offering both conventional and fluorescence imaging, was used. ICG (2.5mg) was administered intravenously immediately after induction of anesthesia and in half of the patients repeated at establishment of Critical View of Safety for concomitant arterial imaging. During dissection of the base of the gallbladder and the cystic duct the extra‐hepatic bile ducts were visualized. Intraoperative recognition of the biliary structures was registered at set time points, as well as visualization of the cystic artery after repeat ICG administration. Results Thirty patients were included. ICG was visible in the liver and bile ducts within 20 minutes after injection and remained so up to approximately 2h, using the ICG‐filter of the laparoscope. In most cases the common bile duct (83%) and cystic duct (97%) could be identified significantly earlier than with conventional camera mode. In 13 of 15 patients (87%) confirmation of the cystic artery was successfully obtained after repeat ICG injection. No per‐ or postoperative complications occurred as a consequence of ICG use. Conclusion Biliary and vascular fluorescence imaging in laparoscopic cholecystectomy is easily applicable in clinical practice, can be helpful for earlier visualization of the biliary tree and is useful for the confirmation of the arterial anatomy. 52
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