Fluorescent Incisionless Cholangiography
A live surgery video preseted by Dr. Fernando Dip, Dr. Jorge Falco, Dr. Raul Pecero, Dr. Fernanda Montesinos, Dr. Lucia Infante and Dr. Raul Rosenthal
Presented here is a case of a patient with symptomatic gallbladder stones who underwent a laparoscopic cholecystectomy with fluorescent cholangiography.
45 minutes before the procedure began, a dose of 0.05 milligrams /kilogram was intravenously administered. ICG is excreted by the liver and stored in the main bile duct.
We begin the laparoscopic procedure in a standard fashion. Once we perform a blunt dissection of the tissue that is in front of the gallbladder, we activate the fluorescent system and we can identify clearly the main bile duct shining from the liver towards the duodenum. We then begin the calots triangle dissection guided by the fluorescent light.
In this case, the main bile duct glows from the beginning of the procedure but the cystic duct showed no fluorescence. Consequently, we perform a reflux maneuver, this is based on compression of the distal to proximal bile duct. ICG is moved into the gallbladder showing clearly the cystic ducts, the main bile duct and the cystic and gallbladder junction.
Once the anatomy is clearly identified under the fluorescent view we can clip and cut the cystic duct and artery safely.
This type of procedure is performed in real time thanks to the overlay of the fluorescent and white light images, which help the surgeon to better identify the calot triangle structures.
We also have a monochromatic mode, a black and white display that, although it does not allow us to operate in real time. ICG allows us to have a greater definition of the margins of the main bile duct and where the cystic duct is located.
Once we carry out the complete dissection of the gallbladder after sectioning the cystic duct and the cystic artery, we evaluate in real time the presence or absence of accessory bile canaliculi in the bed of the gallbladder.
In this particular case, we observed a biliary canaliculus that was in the surgical field and placed a clip on It to avoid postoperative bile leak.