What is the recommended dose of Indocyanine Green (ICG) for laparoscopic cholecystectomy (lap chole)?

Optimal Indocyanine Green Dosing for Laparoscopic Cholecystectomy

The recommended dose of Indocyanine Green (ICG) for laparoscopic cholecystectomy is 0.1 mg administered intravenously 30 minutes before surgery for optimal visualization of biliary structures.

Dosing Recommendations Based on Evidence

Optimal Dosing Strategy

• Low-dose ICG (0.05-0.1 mg) administered 30 minutes preoperatively provides superior visualization of biliary structures compared to standard higher doses 1, 2
• The 0.1 mg dose shows the highest bile duct-to-liver ratio (BLR) before surgical dissection of the cystohepatic triangle 1
• Weight-based dosing at 0.0119 mg/kg administered one hour before surgery has also shown excellent results for extrahepatic biliary tree visualization 3

Timing of Administration

• Administration 30 minutes before surgery provides optimal visualization during the critical phases of the operation 1
• Some studies have used longer intervals (45 minutes to several hours), but recent evidence supports the shorter 30-minute interval for optimal contrast 1, 4

Benefits of ICG Fluorescence Cholangiography

Safety and Efficacy

• ICG fluorescence cholangiography allows visualization of at least one biliary structure in 99% of cases 4
• The cystic duct, common bile duct, and common hepatic duct can be successfully visualized with ICG in 97.8%, 96.1%, and 94% of cases, respectively 4
• No significant adverse reactions have been reported with low-dose ICG administration 5

Surgical Outcomes

• ICG fluorescence cholangiography reduces operative time compared to traditional intraoperative cholangiography (86.9 vs. 117.9 minutes) 5
• Early recognition of anatomical landmarks helps prevent bile duct injuries, which occur in 0.4-0.8% of laparoscopic cholecystectomies 6, 4

Advantages of Low-Dose Protocol

Enhanced Visualization

• Low-dose ICG (0.05-0.1 mg) provides significantly higher bile duct-to-liver and bile duct-to-background fat fluorescence intensity ratios compared to standard doses (2.5 mg) 2
• Lower doses minimize liver fluorescence, creating better contrast for biliary structures 2

Technical Considerations

• ICG is cleared by the liver and excreted into bile, making it ideal for biliary visualization 6
• The use of near-infrared fluorescence technology allows for real-time visualization of biliary structures 6

Clinical Application

Indications for Use

• Particularly valuable in difficult cases with inflammation, obesity, or anatomical variations 6, 5
• Helpful in preventing bile duct injuries by clearly delineating biliary anatomy before dissection 6

Practical Implementation

• Administer 0.1 mg ICG intravenously 30 minutes before surgery
• Use near-infrared fluorescence imaging system during the procedure
• Assess biliary structures before dissection of the cystohepatic triangle and before clipping the cystic duct

Pitfalls and Caveats

• Higher doses (>0.25 mg) can cause excessive liver background fluorescence, reducing contrast between bile ducts and surrounding tissues 1, 2
• Timing is critical - administration too early or too late may reduce effectiveness
• Equipment availability may be a limiting factor as specialized near-infrared imaging systems are required

By following these evidence-based recommendations for ICG dosing in laparoscopic cholecystectomy, surgeons can optimize biliary visualization and potentially reduce the risk of bile duct injuries.