Combined vascular and biliary fluorescence imaging in laparoscopic cholecystectomy Fluorescence laparoscopy The median time interval from preoperative ICG administration until first fluorescence imaging with the laparoscope was 34 (19‐67) minutes. The time until first fluorescence imaging depended mainly on whether an adhesiolysis had to be conducted before initial exposure of the liver hilum could be obtained. After start of surgery the common bile duct could be identified significantly earlier using fluorescence imaging compared with WL imaging (median 23 and 33 minutes respectively; P‐value<0.001). Using fluorescence laparoscopy the cystic duct was delineated after an average of 25 minutes, whereas using WL camera mode this took on average of 36 minutes (P‐value<0.001). See also Table 4.2 for intraoperative registration. Table 4.2 Intraoperative observations 57 Fluorescence cholangiography (n=30) Fluorescence angiography (n=15) Cystic Duct Common Bile Duct Cystic Artery Clear identification of NIRF WL NIRF WL NIRF WL Patients 29/30 (97%) 29/30 (97%) 25/30 (83%) 22/30 (73%) 13/15 (87%) # 13/15 (87%) # Median time in minutes range 25 5‐49 36 9‐69 23 5‐65 33 9‐65 P<0.001* P<0.001* * Significant difference (P<0.05); # In 2 cases the cystic artery was already dissected before repeat ICG injection Using fluorescence cholangiography the CBD and the CD could be clearly visualized and delineated before dissection of Calot’s triangle (Figure 4.2A), respectively in 25/30 patients (83%) and 29/30 patients (97%). In four of five cases (17%), in which the CBD could not be visualized using fluorescence imaging, a chronic inflammation of the gallbladder was present. One patient appeared to have a chronic, focally active cholecystitis. BMI of these patients ranged from 26.35 to 31.14 kg/m2. However, in the 25 patients in whom the CBD could be delineated before dissection, there were also cases of chronic inflamed gallbladders and BMIs within the same range as these 5 patients. Conventional laparoscopy provided certainty on the course of the CBD and the CD in respectively 22/30 patients and 29/30 patients. In one patient conversion to open cholecystectomy followed, due to insufficient sight on the liver hilum after an early perforation of a very thin‐walled gallbladder, causing persistent nuisance bile leakage. Critical view of safety was obtained in a median of 45 minutes after incision. Concomitant fluorescence angiography of the cystic artery (Figure 4.2B) was successful
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