Combined vascular and biliary fluorescence imaging in laparoscopic cholecystectomy 55 Patient undergoing elective laparoscopic cholecystectomy Preoperative Intraoperative Postoperative Patient eligible for inclusion? Informed consent? Intravenous ICG injection directly after induction of anesthesia Start laparoscopic procedure using conventional camera mode Every 5‐10 minutes switch camera to ICG‐mode for fluorescence cholangiography, until CVS is established Visualization of extra‐hepatic bile ducts (conventional vs. ICG imaging) registered Repeat ICG injection at establishment of CVS for concomitant fluorescence angiography Figure 4.1 Flowchart of the NIRFC‐LC study procedures Data analysis of registered time measurements Video‐assessment for quantitative fluorescence image analysis Data collection Intraoperatively a researcher systematically registered on a paper form whether the localization of the common bile duct, cystic duct and 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 attending surgeon was consulted. A structure was scored as ‘identified’ if its localization was confirmed with great certainty by the experienced surgeon. In case of the common bile duct this does explicitly not mean that it was surgically exposed, as this is contradictory to the CVS‐technique. During all laparoscopic cholecystectomies the full surgical procedure was recorded on DVD, thereby collecting both conventional and fluorescence images. After completion of surgery, length of time between the introduction of the laparoscope until the first recognition of the following components were calculated, based on the intraoperative registration: common bile duct (CBD), cystic duct (CD), cystic artery (CA) and Critical View of Safety (CVS). Using conventional imaging the CBD is regularly not displayed; this is partly a result of the CVS technique. The mean ‘total fluorescence imaging time’ during the laparoscopic
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