Chapter 4 Looking at the results of the quantitative fluorescence image analysis, the moment of ICG administration (directly after induction of anesthesia) seems appropriate for the laparoscopic cholecystectomy procedure: a timely and continuous intraoperative detection of biliary structures can be obtained. Also from a practical and logistical point of view the applied timing of administration is appropriate. In this study not only uncomplicated cholecystolithiasis patients, but also more complicated cases, such as cholecystitis or cholecystectomy after biliary pancreatitis, were included. Fluorescence cholangiography and angiography was successful in almost all cases, and no difference was found in image quality between the uncomplicated and complicated procedures. However, presence of factors as (either chronic or active) cholecystitis or obesity might compromise the efficacy of the new imaging modality. The actual impact of such conditions should be further investigated by conducting a univariate and multivariate analysis in a study population (large enough for this kind of analysis) to determine the risk factors. This was not possible in the current group of patients. The near‐infrared fluorescence laparoscopy technique possesses potential to enter the clinical practice in the near future. However, optimization of the current laparoscopic imaging systems is needed to make them more easily applicable in the operating room. Current laparoscopic systems do not yet possess the ability to display the fluorescence image in anatomical context. Furthermore, penetration depth at which the imaging system can detect a fluorophore in tissues needs improvement (currently up to maximum of 1 centimeter). An increase in fluorescence capabilities of contrast agents is also desirable25. A comparison with conventional intraoperative cholangiography would be desirable. However, intraoperative cholangiography is only rarely applied in the Netherlands and many parts of the world. Intraoperative cholangiography has been suggested to reduce the risk of bile duct injury1,10. However, this radiological imaging of the biliary tree is only used selectively, as the process takes time, radiation exposure is involved and additional equipment and manpower for the procedure are required. Moreover, worldwide consensus about implementation of intraoperative cholangiography is still lacking26. It could be argued that the fluorescence laparoscopy technique is especially useful for the less experienced surgeon to perform safe laparoscopic gallbladder removal, or in more complicated cholecystectomies. However, it may be most effective when performed routinely in all cases. Increased costs are involved in terms of the light source, camera and fluorescent dye. However, it is anticipated that worldwide, standard application of this technique will be accompanied by cheaper devices and 60
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