Real-time Visualisation of the Extrahepatic Biliary System Using Indocyanine Green Fluorescence Cholangiography During Laparoscopic Cholecystectomy: A Prospective Cross-sectional Single-centre Study of 199 Cases
- 1Senior Resident, Department of Surgical Gastroenterology, Nizam Institute of Medical Sciences, Hyderabad, Telangana, India.
- 2Assistant Professor, Department of General Surgery, Subbaiah Institute of Medical Sciences and Research Centre, Shimoga, Karnataka, India.
- 3Research Associate, Department of Public Health, Blue Peter Public Health and Research Centre, Hyderabad, Telangana, India.
Abstract
Introduction: Bile Duct Injury (BDI) is an infrequent but serious complication of Laparoscopic Cholecystectomy (LC) and is frequently related to misidentification of biliary anatomy. Conventional Intraoperative Cholangiography (IOC) is invasive, requires fluoroscopy and may be technically difficult in inflamed or distorted anatomy. Fluorescent Cholangiography (FC) using Indocyanine Green (ICG) and Near Infrared (NIR) imaging permits real-time visualisation of the extrahepatic biliary tree without radiation. Aim: To determine the visualisation rate of the Cystic Duct (CD), Common Hepatic Duct (CHD), Common Bile Duct (CBD) and CD-CHD confluence under ICG-NIR fluorescent cholangiography at the stage of the Critical View of Safety (CVS) during LC. Materials and Methods: A single-centre prospective cross-sectional observational study was conducted at the Department of Surgery and Surgical Gastroenterology, Meenakshi Mission Hospital and Research Centre (MMHRC), Madurai, Tamil Nadu, India from October 2016 to September 2018. A total of 199 consecutive patients (≥15 years) undergoing elective or emergency LC received intravenous ICG (0.05 mg/kg, max 5 mg of 2.5 mg/mL solution) 90 minutes before skin incision. NIR imaging (Stryker 1588 AIM and Karl Storz SPIES/IMAGE1 S systems) was used intraoperatively. Visualisation was independently rated by two senior surgeons (Cohen’s kappa=0.82). Cases were classified as simple or complex on operative pathology. Data were analysed using IBM Statistical Package for Social Sciences (SPSS) version 26.0; Chi-square/Fisher’s-exact tests with 95% Wilson confidence intervals were applied (p<0.05 significant). Results: Of 199 patients, 94/199 (47.2%) were male and 105/199 (52.8%) female; mean age 49.4±15.7 years; mean BMI 25.7±5.1 kg/m². Simple cases: 107/199 (53.8%); complex cases: 92/199 (46.2%). Overall visualisation rates at CVS were CD 168/199 (84.4%; 95% CI 78.7-88.9), CHD 165/199 (82.9%; 77.1-87.6), CBD 182/199 (91.4%; 86.7-94.7) and CD-CHD confluence 172/199 (86.4%; 80.9-90.6). In simple vs complex cases, respectively: CD 99.0% vs 67.3% (p<0.001); CBD 100% vs 81.5% (p<0.001). Anatomical variations included short CD (22/199, 11.1%), long CD (20/199, 10.1%), independent right posterior sectoral duct (17/199, 8.5%), trifurcation at CHD (5/199, 2.5%) and Phrygian cap (3/199, 1.5%). There were no conversions, no BDI and no ICG-related allergic reactions. One postoperative death occurred from sudden cardiac arrest (unrelated to ICG). Conclusion: ICG-NIR fluorescent cholangiography is a safe and useful adjunct for real-time visualisation of extrahepatic biliary anatomy during LC. Visualisation is reduced in complex inflammatory cases, but the technique still facilitates identification of key ducts and anatomical variations and may enhance surgical safety when combined with the CVS principle.
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BibTeX
@article{aditya2026realtime,
title = {{Real-time Visualisation of the Extrahepatic Biliary System Using Indocyanine Green Fluorescence Cholangiography During Laparoscopic Cholecystectomy: A Prospective Cross-sectional Single-centre Study of 199 Cases}},
author = {C Aditya and Abhijit Acharya and N Mohan and KG Sruthi},
journal = {Journal of Clinical and Diagnostic Research},
year = {2026},
month = nov,
doi = {10.7860/jcdr/2026/84088.24697},
url = {https://doi.org/10.7860/jcdr/2026/84088.24697},
note = {CC BY-NC-ND},
}
RIS
TY - JOUR
TI - Real-time Visualisation of the Extrahepatic Biliary System Using Indocyanine Green Fluorescence Cholangiography During Laparoscopic Cholecystectomy: A Prospective Cross-sectional Single-centre Study of 199 Cases
AU - C Aditya
AU - Abhijit Acharya
AU - N Mohan
AU - KG Sruthi
PY - 2026
DA - 2026/11/04
JO - Journal of Clinical and Diagnostic Research
DO - 10.7860/jcdr/2026/84088.24697
UR - https://doi.org/10.7860/jcdr/2026/84088.24697
AB - Introduction: Bile Duct Injury (BDI) is an infrequent but serious complication of Laparoscopic Cholecystectomy (LC) and is frequently related to misidentification of biliary anatomy. Conventional Intraoperative Cholangiography (IOC) is invasive, requires fluoroscopy and may be technically difficult in inflamed or distorted anatomy. Fluorescent Cholangiography (FC) using Indocyanine Green (ICG) and Near Infrared (NIR) imaging permits real-time visualisation of the extrahepatic biliary tree without radiation. Aim: To determine the visualisation rate of the Cystic Duct (CD), Common Hepatic Duct (CHD), Common Bile Duct (CBD) and CD-CHD confluence under ICG-NIR fluorescent cholangiography at the stage of the Critical View of Safety (CVS) during LC. Materials and Methods: A single-centre prospective cross-sectional observational study was conducted at the Department of Surgery and Surgical Gastroenterology, Meenakshi Mission Hospital and Research Centre (MMHRC), Madurai, Tamil Nadu, India from October 2016 to September 2018. A total of 199 consecutive patients (≥15 years) undergoing elective or emergency LC received intravenous ICG (0.05 mg/kg, max 5 mg of 2.5 mg/mL solution) 90 minutes before skin incision. NIR imaging (Stryker 1588 AIM and Karl Storz SPIES/IMAGE1 S systems) was used intraoperatively. Visualisation was independently rated by two senior surgeons (Cohen’s kappa=0.82). Cases were classified as simple or complex on operative pathology. Data were analysed using IBM Statistical Package for Social Sciences (SPSS) version 26.0; Chi-square/Fisher’s-exact tests with 95% Wilson confidence intervals were applied (p<0.05 significant). Results: Of 199 patients, 94/199 (47.2%) were male and 105/199 (52.8%) female; mean age 49.4±15.7 years; mean BMI 25.7±5.1 kg/m². Simple cases: 107/199 (53.8%); complex cases: 92/199 (46.2%). Overall visualisation rates at CVS were CD 168/199 (84.4%; 95% CI 78.7-88.9), CHD 165/199 (82.9%; 77.1-87.6), CBD 182/199 (91.4%; 86.7-94.7) and CD-CHD confluence 172/199 (86.4%; 80.9-90.6). In simple vs complex cases, respectively: CD 99.0% vs 67.3% (p<0.001); CBD 100% vs 81.5% (p<0.001). Anatomical variations included short CD (22/199, 11.1%), long CD (20/199, 10.1%), independent right posterior sectoral duct (17/199, 8.5%), trifurcation at CHD (5/199, 2.5%) and Phrygian cap (3/199, 1.5%). There were no conversions, no BDI and no ICG-related allergic reactions. One postoperative death occurred from sudden cardiac arrest (unrelated to ICG). Conclusion: ICG-NIR fluorescent cholangiography is a safe and useful adjunct for real-time visualisation of extrahepatic biliary anatomy during LC. Visualisation is reduced in complex inflammatory cases, but the technique still facilitates identification of key ducts and anatomical variations and may enhance surgical safety when combined with the CVS principle.
SN - 2249-782X
SN - 0973-709X
ER -