Combined vascular and biliary fluorescence imaging in laparoscopic cholecystectomy Complications No per‐ or postoperative complications regarding the extra‐hepatic bile ducts occurred. There was one conversion from laparoscopic to open cholecystectomy. None of the patients developed any adverse reactions to the injected ICG. 59 Discussion This prospective, single‐institutional, clinical study showed that the near‐infrared fluorescence imaging technique was useful for earlier bile duct delineation during laparoscopic cholecystectomy. Next, it was found that repeat ICG injection at establishment of Critical View of Safety was helpful in the confirmation of arterial anatomy, in particular the course of the cystic artery. The fluorescence technique provided a significantly earlier identification and a clear delineation (high TBR) of the common bile duct, the cystic duct and the cystic artery, therewith assisting in safe and efficient dissection of the gallbladder according to the CVS technique. The near‐infrared fluorescence technique after local or intravenous administration of ICG has been evaluated in open, laparoscopic, single‐incision laparoscopic and robotic single‐site cholecystectomy13‐18. Promising results were presented for successful intraoperative identification of the common bile duct and the cystic duct, compared to conventional laparoscopic imaging. The results of the present study showed moreover that fluorescence laparoscopy provided significantly earlier identification of the extra‐hepatic bile ducts during dissection. Real‐time simultaneous imaging of the bile ducts and the arterial anatomy (i.e. hepatic and cystic arteries) can also be obtained13,19‐21. This study confirmed the possibility of concomitant vascular (i.e. cystic artery) and biliary (i.e. cystic duct and common bile duct) imaging at establishment of Critical View of Safety. Implementation of conducting both fluorescence cholangiography and angiography can be helpful in cases in which the establishment of CVS is challenging. Furthermore it may facilitate the intraoperative detection of bile duct and possible concomitant vasculobiliary injury (e.g. hepatic artery). The latter is an increasingly recognized complication of laparoscopic cholecystectomy22. Such combined injury negatively affects the outcome of bile duct injury repair6,23. Based on a review of vasculobiliary injury in laparoscopic and open cholecystectomy, routine arteriography in patients with biliary injury has been recommended24. The negligible extension of operation duration in this study, related to the use of the fluorescence technique, will probably further decrease with growing experience.
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