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Near-infrared cholecysto-cholangiography with indocyanine green may secure cholecystectomy in difficult clinical situations: proof of the concept in a porcine model

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Abstract

Background

Biliary injuries remain a major concern in laparoscopic cholecystectomy. New intraoperative guidance modalities, including near-infrared fluorescence cholangiography, are under evaluation. Initial results showed limitations in visualizing the biliary tree in specific clinical situations. The aim of this study was to examine the feasibility and potentiality of fluorescence cholecysto-cholangiography performed with a direct injection of indocyanine green (ICG) in the gallbladder and to compare it to systemic injection in such situations.

Materials and methods

Seven pigs were included in this non-survival study. In two pigs, the gallbladder was punctured by a percutaneous needle, and 1 mL of ICG in different concentrations (0.001, 0.01, 0.1, and 1 mg/mL) was sequentially injected. Visibility and pattern of the fluorescent signal around Calot’s triangle were examined and compared with those of two control pigs receiving 2.5 mg of intravenous ICG, 30 min prior to the operation. Different scenarios of cholecystitis were modeled using an injection of a mixture of blood and agarose gel around Calot’s triangle area in the remaining three pigs, and the applicability of direct intragallbladder injection methods was evaluated.

Results

The fluorescent signal was identified immediately after intragallbladder injection, and the cystic duct became visible by 0.1 and 1 mg/mL of ICG. The whole cystic duct and the infundibulum of the gallbladder were clearly enhanced by intragallbladder ICG injection, but not by systemic injection. In the cholecystitis models, the cystic duct could be identified only after partial dissection, and fluorescence visualization of the gallbladder infundibulum provided crucial information to find the correct starting point of dissection.

Conclusions

Fluorescence cholecysto-cholangiography through direct intragallbladder ICG injection could rapidly provide an adequate visualization of gallbladder neck and cystic duct and might be a valid option to increase the safety of cholecystectomy in case of cholecystitis.

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Acknowledgments

Authors are grateful to Mathilde Raux-Defossez, Christopher Burel, and Guy Temporal, for their assistance in proofreading the manuscript.

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Author notes

    Authors and Affiliations

    1. IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France

      Yu-Yin Liu, Michele Diana, Chun-Chi Wu, Noriaki Kameyama, Bernard Dallemagne & Jacques Marescaux

    2. Department of General Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan

      Yu-Yin Liu

    3. IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France

      Seong-Ho Kong, Michele Diana, Andras Lègner & Jacques Marescaux

    4. Department of Surgery, Seoul National University Hospital, Seoul, South Korea

      Seong-Ho Kong

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    1. Yu-Yin Liu
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    Correspondence to Bernard Dallemagne.

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    Disclosures

    Jacques Marescaux is the President of both IRCAD and IHU Institutes, which are partly funded by Karl Storz Endoskope, Covidien, and Siemens Healthcare. Yu-Yin Liu, Seong-Ho Kong, Michele Diana, Andras Lègner, Chun-Chi Wu, Noriaki Kameyama, Bernard Dallemagne, and Jacques Marescaux have no conflicts of interest or financial ties to disclose.

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    Yu-Yin Liu and Seong-Ho Kong have equally contributed to this work.

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    Liu, YY., Kong, SH., Diana, M. et al. Near-infrared cholecysto-cholangiography with indocyanine green may secure cholecystectomy in difficult clinical situations: proof of the concept in a porcine model. Surg Endosc 30, 4115–4123 (2016). https://doi.org/10.1007/s00464-015-4608-9

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