Combined vascular and biliary fluorescence imaging in laparoscopic cholecystectomy 53 Introduction Bile duct injury is a rare but severe complication in patients undergoing laparoscopic cholecystectomy (0.3‐0.7%)1‐4. Misidentification of the extra‐hepatic bile duct anatomy during this procedure is the main cause of such injury5. Concomitant vasculobiliary injury negatively affects the outcome of bile duct injury repair6. The Critical View of Safety (CVS) technique, which was first described by Strasberg in 19957 and recommended by the SAGES Annual Meeting of 20058, was introduced to reduce the risk of bile duct injury. To establish CVS, two windows need to be created during dissection of Calot’s triangle: one window between the cystic artery, cystic duct and gallbladder, another window between the cystic artery, gallbladder and liver. The CVS technique is especially aimed at mobilizing the gallbladder neck from the liver, in order to obtain a circumferential identification of the cystic duct. Near‐infrared fluorescence laparoscopy with preoperative intravenous injection of indocyanine green (ICG) is a promising, innovative and noninvasive imaging method for enhanced intraoperative visualization of biliary anatomy. It has the potential to improve outcome of the laparoscopic cholecystectomy procedure9,10. ICG is cleared quickly and exclusively by the liver after intravenous administration and has few, if any side effects, making it an ideal fluorophore for this application. Previous experience with intermittent fluorescence cholangiography during elective laparoscopic cholecystectomy showed that this technique can indeed accelerate biliary tract delineation11. In the present part of a larger feasibility study project on fluorescence laparoscopy technique, simultaneous fluorescence cholangiography and angiography at the moment of establishing CVS were conducted. The main objective of this study was to test the practical applicability of a newly developed laparoscopic fluorescence imaging system during elective laparoscopic cholecystectomy, regarding real‐time intraoperative biliary and arterial imaging. Materials and methods This study was performed at the department of Surgery of the Maastricht University Medical Center (MUMC, Maastricht, The Netherlands) between December 2011 and October 2012. All operations were performed by a surgical resident, assisted by a surgeon with a track record of at least 150 laparoscopic cholecystectomies. The institutional review board (IRB) of the MUMC approved of this study. The study was registered in the Netherlands National Trial Register:
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