Role of Indocyanine Green (ICG) in Laparoscopic Cholecystectomy
Indocyanine Green (ICG) fluorescence cholangiography is recommended as a selective adjunct during difficult laparoscopic cholecystectomy to enhance biliary tract visualization and increase the rate of intraoperative diagnosis when bile duct injury is suspected, though routine use to reduce bile duct injury rates is not yet recommended. 1, 2
Benefits of ICG in Laparoscopic Cholecystectomy
- ICG provides real-time imaging of the extrahepatic biliary tract during laparoscopic cholecystectomy as a noninvasive, quick, safe, and easy-to-apply tool 1
- ICG fluorescence enables visualization of biliary structures within 20 minutes after injection and remains visible for approximately 2 hours 3
- ICG cholangiography can identify the cystic duct in up to 97% of cases and the common bile duct in 83% of cases, significantly earlier than with conventional visualization 3
- ICG fluorescence can help identify the cystic duct-common hepatic duct junction before dissection of Calot's triangle in most patients (96%) 4
- ICG can also be used for vascular imaging, with successful confirmation of the cystic artery in 87% of cases after repeat ICG injection 3
Clinical Application and Technique
- ICG (2.5 mg) is typically administered intravenously immediately after induction of anesthesia 3
- A dedicated laparoscope with near-infrared imaging capability is required to visualize the fluorescence 3, 5
- Alternative technique: direct gallbladder ICG injection can provide immediate visualization of extrahepatic biliary structures and clarify the dissection plane between the gallbladder and liver bed 6
- ICG fluorescence allows successful visualization of at least one biliary structure in 100% of cases 5
Recommendations and Limitations
- ICG should be considered as an adjunct to, not a replacement for, the critical view of safety technique during laparoscopic cholecystectomy 2
- The World Society of Emergency Surgery (WSES) recommends selective use of adjuncts like ICG for biliary tract visualization during difficult laparoscopic cholecystectomy or whenever bile duct injury is suspected 1
- When comparing ICG cholangiography to intraoperative cholangiography (IOC), studies found no significant differences for visualization of the cystic duct, common bile duct, or common hepatic duct 1
- Despite its benefits, a survey of 3,411 experienced surgeons found that routine use of adjuncts such as ICG, IOC, or intraoperative ultrasound during difficult cholecystectomies was not significantly associated with a lower risk of bile duct injuries 1
Emerging Concepts: Critical View of Safety Plus
- The "Critical View of Safety Plus" concept combines traditional critical view of safety with ICG fluorescence imaging 7
- This approach may improve visualization of the biliary tree and identification of aberrant biliary anatomy 7
- Studies show surgeons are more likely to proceed with clipping and cutting when using Critical View of Safety Plus compared to traditional Critical View of Safety (58% vs 44%) 7
- Critical View of Safety Plus showed improved scores for cystic plate clearance and hepatocystic triangle clearance compared to traditional Critical View of Safety 7
Practical Considerations
- ICG fluorescence is particularly valuable in cases with difficult anatomy or acute cholecystitis 2
- In cases of suspected bile duct injury, asking the opinion of another surgeon (physically or virtually) may be an easy, effective, and inexpensive alternative to IOC 1
- Geographic distance between facilities, equipment availability, expertise, and logistics significantly influence the implementation of ICG cholangiography across institutions 1
- ICG has minimal reported complications when used for biliary visualization during laparoscopic cholecystectomy 3