Optimal Timing for Indocyanine Green (ICG) Injection During Laparoscopic Cholecystectomy
For optimal visualization during laparoscopic cholecystectomy, ICG should be administered intravenously at a dose of 0.1 mg approximately 30 minutes before surgery.
ICG Administration Timing and Dosage
The timing and dosage of ICG administration are critical factors for achieving optimal visualization of biliary structures during laparoscopic cholecystectomy:
- Recommended timing: 30 minutes before surgery for standard procedures 1
- Optimal dose: 0.1 mg administered intravenously 1, 2
- Alternative timing: 15 hours before surgery if using the PINPOINT® Endoscopic Fluorescence Imaging System specifically 3
A randomized controlled trial comparing different ICG doses administered 30 minutes preoperatively found that 0.1 mg provided the highest bile duct-to-liver ratio (BLR), which is essential for clear visualization of biliary structures before dissection of the cystohepatic triangle 1.
Mechanism of Action and Benefits
ICG is cleared by the liver and excreted into bile, making it ideal for biliary visualization:
- ICG provides real-time, non-invasive imaging of extrahepatic biliary structures 2
- Enables earlier visualization of the common bile duct and cystic duct compared to conventional imaging 2
- Helps achieve the critical view of safety during cholecystectomy 4
- Reduces operative time compared to traditional intraoperative cholangiography 2
Special Considerations
Alternative Administration Methods
- Direct gallbladder injection: Can be used in select cases for real-time fluorescent cholangiography and optimal critical view of safety 4
- Weight-based dosing: Some studies suggest a weight-based approach using 0.0119 mg/kg administered one hour before surgery 5
Equipment Considerations
Different fluorescence imaging systems may require different timing:
- Standard systems: 30 minutes before surgery 1
- PINPOINT® Endoscopic Fluorescence Imaging System: 15 hours before surgery for optimal contrast between biliary structures and liver 3
Clinical Applications and Safety
ICG fluorescence cholangiography is particularly valuable in difficult cases with inflammation, obesity, or anatomical variations 2. The World Society of Emergency Surgery considers ICG-C a promising non-invasive tool, though routine use to reduce bile duct injury rates is not yet recommended (Weak recommendation, low quality of evidence) 6, 2.
No significant adverse reactions have been reported with low-dose ICG administration, making it a safe option for patients undergoing laparoscopic cholecystectomy 2.
Pitfalls to Avoid
- Excessive dosing: Higher doses (>0.25 mg) can lead to excessive liver fluorescence, which may obscure biliary structures 1
- Inadequate timing: Administration too close to surgery may not allow sufficient time for ICG to be excreted into the biliary system
- Relying solely on ICG: While helpful, ICG should complement, not replace, the critical view of safety technique for preventing bile duct injuries 6
Remember that while ICG cholangiography is a valuable tool, it should be used as an adjunct to proper surgical technique and the critical view of safety to minimize the risk of bile duct injury during laparoscopic cholecystectomy.