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Lin W, Tao H, Zeng X, Wang J, Zhu W, Zeng N, Xiang N, Liu J, Fang C, Yang J. Efficacy of Intraoperative vs Preoperative Indocyanine Green Administration for Near-Infrared Cholangiography During Laparoscopic Cholecystectomy: An Open-Label, Noninferiority, Randomized Controlled Trial. J Am Coll Surg 2025; 240:245-253. [PMID: 39412164 DOI: 10.1097/xcs.0000000000001226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2025]
Abstract
BACKGROUND Near-infrared fluorescence cholangiography improves the clinical effects of laparoscopic cholecystectomy. However, the administration of indocyanine green remains controversial. Both the intraoperative strategy (IS, 0.05 mg) and preoperative strategy (PS, 0.25 mg/kg body weight, 1 day before operation) have been shown to be superior to the standard strategy (2.5 mg, intraoperative). This trial was designed to determine whether IS offers noninferior visualization of biliary ducts compared with PS. STUDY DESIGN A total of 168 eligible patients undergoing laparoscopic cholecystectomy were enrolled in this noninferiority, open-label, randomized controlled trial at Zhujiang hospital between August 2023 and November 2023. Participants were randomized in a 1:1 ratio into PS and IS groups after stratification by BMI and inflammation level. The fluorescence visualization of biliary structures was assessed by comparing the signal-to-background ratio (SBR) and surgeon evaluations. RESULTS The common bile duct-liver SBR did not significantly differ between IS and PS groups (3.0 ± 0.8 vs 3.1 ± 1.2; p = 0.636). The liver fluorescence intensity of the IS group was significantly lower than that of the PS group (46.3 ± 12.9 vs 70.4 ± 26.2; p < 0.01). The visualization score of common hepatic ducts was significantly greater in the IS than in the PS group (4.1 ± 0.7 vs 3.7 ± 0.6; p< 0.01). The critical view of safety was achieved more rapidly in the IS group compared with the PS group (9.4 vs 11.0 minutes, p < 0.01). CONCLUSIONS Although IS did not improve the SBR, it significantly reduced the fluorescence intensity of the liver background, potentially enhancing the surgeon's subjective perception and thereby increasing the visualization score. Compared with PS, IS offers greater convenience and is more effective in facilitating critical view of safety exposure.
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Affiliation(s)
- Wenjun Lin
- From the Department of Hepatobiliary Surgery I, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
- Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
| | - Haisu Tao
- From the Department of Hepatobiliary Surgery I, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
- Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
| | - Xiaojun Zeng
- From the Department of Hepatobiliary Surgery I, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
- Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
| | - Junfeng Wang
- From the Department of Hepatobiliary Surgery I, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
- Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
| | - Wen Zhu
- From the Department of Hepatobiliary Surgery I, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
- Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
| | - Ning Zeng
- From the Department of Hepatobiliary Surgery I, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
- Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
| | - Nan Xiang
- From the Department of Hepatobiliary Surgery I, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
- Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
| | - Jun Liu
- From the Department of Hepatobiliary Surgery I, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
- Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
| | - Chihua Fang
- From the Department of Hepatobiliary Surgery I, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
- Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
| | - Jian Yang
- From the Department of Hepatobiliary Surgery I, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
- Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, China (Lin, Tao, X Zeng, Wang, Zhu, N Zeng, Xiang, Liu, Fang, Yang)
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De Simone B, Abu-Zidan FM, Boni L, Castillo AMG, Cassinotti E, Corradi F, Di Maggio F, Ashraf H, Baiocchi GL, Tarasconi A, Bonafede M, Truong H, De'Angelis N, Diana M, Coimbra R, Balogh ZJ, Chouillard E, Coccolini F, Kelly MD, Di Saverio S, Di Meo G, Isik A, Leppäniemi A, Litvin A, Moore EE, Pasculli A, Sartelli M, Podda M, Testini M, Wani I, Sakakushev B, Shelat VG, Weber D, Galante JM, Ansaloni L, Agnoletti V, Regimbeau JM, Garulli G, Kirkpatrick AL, Biffl WL, Catena F. Indocyanine green fluorescence-guided surgery in the emergency setting: the WSES international consensus position paper. World J Emerg Surg 2025; 20:13. [PMID: 39948641 PMCID: PMC11823064 DOI: 10.1186/s13017-025-00575-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2024] [Accepted: 01/04/2025] [Indexed: 02/16/2025] Open
Abstract
BACKGROUND Decision-making in emergency settings is inherently complex, requiring surgeons to rapidly evaluate various clinical, diagnostic, and environmental factors. The primary objective is to assess a patient's risk for adverse outcomes while balancing diagnoses, management strategies, and available resources. Recently, indocyanine green (ICG) fluorescence imaging has emerged as a valuable tool to enhance surgical vision, demonstrating proven benefits in elective surgeries. AIM This consensus paper provides evidence-based and expert opinion-based recommendations for the standardized use of ICG fluorescence imaging in emergency settings. METHODS Using the PICO framework, the consensus coordinator identified key research areas, topics, and questions regarding the implementation of ICG fluorescence-guided surgery in emergencies. A systematic literature review was conducted, and evidence was evaluated using the GRADE criteria. A panel of expert surgeons reviewed and refined statements and recommendations through a Delphi consensus process, culminating in final approval. RESULTS ICG fluorescence imaging, including angiography and cholangiography, improves intraoperative decision-making in emergency surgeries, potentially reducing procedure duration, complications, and hospital stays. Optimal use requires careful consideration of dosage and timing due to limited tissue penetration (5-10 mm) and variable performance in patients with significant inflammation, scarring, or obesity. ICG is contraindicated in patients with known allergies to iodine or iodine-based contrast agents. Successful implementation depends on appropriate training, availability of equipment, and careful patient selection. CONCLUSIONS Advanced technologies and intraoperative navigation techniques, such as ICG fluorescence-guided surgery, should be prioritized in emergency surgery to improve outcomes. This technology exemplifies precision surgery by enhancing minimally invasive approaches and providing superior real-time evaluation of bowel viability and biliary structures-areas traditionally reliant on the surgeon's visual assessment. Its adoption in emergency settings requires proper training, equipment availability, and standardized protocols. Further research is needed to evaluate cost-effectiveness and expand its applications in urgent surgical procedures.
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Affiliation(s)
- Belinda De Simone
- Department of Emergency and General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy.
- Department of Theoretical and Applied Sciences, eCampus University, Novedrate, CO, Italy.
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, UAE
| | - Luigi Boni
- Department of General and Minimally Invasive Surgery, Fondazione IRCCS - Ca' Granda - Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Ana Maria Gonzalez Castillo
- Emergency Surgery Unit, Department of General Surgery, Pompeu Fabra University, Hospital del Mar, Barcelona, Spain
| | - Elisa Cassinotti
- Department of General and Minimally Invasive Surgery, Fondazione IRCCS - Ca' Granda - Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Francesco Corradi
- Department of Surgical, Medical andMolecularPathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Francesco Di Maggio
- Upper Gastro-Intestinal Surgery Unit, Department of General Surgery, Croydon University Hospital, London, UK
| | - Hajra Ashraf
- Upper Gastro-Intestinal Surgery Unit, Department of General Surgery, Croydon University Hospital, London, UK
| | - Gian Luca Baiocchi
- Unit of General Surgery, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | | | - Hung Truong
- Acute Care and Minimally Invasive Surgery, Scripps Memorial Hospital - La Jolla, Green, and Encinitas, La Jolla, USA
| | - Nicola De'Angelis
- Unit of Robotic and Minimally Invasive Digestive Surgery, Ferrara University Hospital, Ferrara, Italy
| | - Michele Diana
- Department of Surgery, University Hospital of Geneva, 1205, Geneva, Switzerland
- ICube Laboratory, Photonics Instrumentation for Health, 67034, Strasbourg, France
| | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Elie Chouillard
- General Surgery Department, American Hospital of Paris, Paris, France
| | | | | | - Salomone Di Saverio
- General Surgery Unit, Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Arda Isik
- Istanbul Medeniyet University, Istanbul, Turkey
| | - Ari Leppäniemi
- Division of Emergency Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrey Litvin
- Department of Surgical Diseases No. 3, Gomel State Medical University, University Clinic, Gomel, Belarus
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Alessandro Pasculli
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Mauro Podda
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Imtiaz Wani
- Department of Surgery, Government Gousia Hospital, DHS, Srinagar, India
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital & The University of Western Australia, Perth, Australia
| | - Joseph M Galante
- UC Davis Health, Hospital Clinical Care Services, University of California, Davis, USA
| | - Luca Ansaloni
- Department of General Surgery, University of Pavia, Pavia, Italy
| | - Vanni Agnoletti
- Level 1 Trauma Center, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Jean-Marc Regimbeau
- Service de Chirurgie Digestive du CHU d'Amiens, CHU Sud, Centre Hospitalier Universitaire Amiens-Picardie Site Sud, 80054, Amiens, France
| | - Gianluca Garulli
- Department of Emergency and General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy
| | - Andrew L Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, AUSL Romagna, Cesena, Italy
- Alma Mater Studiorum, University of Bologna, Bologna, Italy
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Nishino S, Igami T, Yokoyama Y, Mizuno T, Yamaguchi J, Onoe S, Sunagawa M, Watanabe N, Baba T, Kawakatsu S, Ebata T. Application of fluorescent cholangiography to complex biliary variants of the confluence of the cystic duct and the infraportal type of the left lateral bile duct during single-incision laparoscopic cholecystectomy: A case report. Asian J Endosc Surg 2025; 18:e13404. [PMID: 39511846 DOI: 10.1111/ases.13404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2024] [Revised: 09/02/2024] [Accepted: 10/22/2024] [Indexed: 11/15/2024]
Abstract
A 21-year-old man was diagnosed with segmental adenomyomatosis of the gallbladder based on ultrasonography and computed tomography images. Computed tomography with drip infusion cholangiography revealed that the cystic duct joined the infraportal type of the left lateral bile duct (IPLLBD), which runs caudal to the umbilical portion, and that the left medial bile duct joined the right hepatic duct without forming the left hepatic duct. We planned a single-incision laparoscopic cholecystectomy with fluorescent cholangiography. The fluorescent cholangiography visualized the anatomic variant of the biliary system, and the cystic duct was divided safely. Fluorescent cholangiography is a suitable procedure to depict complex biliary anatomic variations in this patient. IPLLBD without the formation of the left hepatic duct is potentially hazardous during cholecystectomy.
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Affiliation(s)
- Shinji Nishino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsuyoshi Igami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Junpei Yamaguchi
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shunsuke Onoe
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masaki Sunagawa
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuyuki Watanabe
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Taisuke Baba
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shoji Kawakatsu
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Kim SH, Lee S. Determining the patency of biliary tracts in dogs with gallbladder mucocele using near-infrared cholangiography with indocyanine green. PLoS One 2024; 19:e0300395. [PMID: 38776340 PMCID: PMC11111041 DOI: 10.1371/journal.pone.0300395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/27/2024] [Indexed: 05/24/2024] Open
Abstract
Cholecystectomy is indicated for gallbladder mucoceles (GBM). Evaluating the patency of the biliary duct and precise biliary tree visualization is crucial for reducing the risk of compromised bile flow after surgery. Therefore, intraoperative cholangiography (IOC) is recommended during cholecystectomy to prevent biliary tract injury. Although indocyanine green (ICG) cholangiography has been extensively reported in human medicine, only one study has been conducted in veterinary medicine. Therefore, this study aimed to demonstrate the use of ICG for IOC to identify fluorescent biliary tract images and determine the patency of the common bile duct during cholecystectomy in dogs. This study comprised 27 dogs, consisting of 17 with gallbladder mucoceles (GBM) and 10 controls, specifically including dogs that had undergone elective cholecystectomy for GBM. ICG injection (0.25 mg/kg) was administered intravenously at least 45 minutes before surgery. During the operation, fluorescent images from cholangiography were displayed on the monitor and obtained in black-and-white mode for the comparison of fluorescence intensity (FI). The FI values of the gallbladders (GBs) and common bile duct (CBD) were measured using FI analyzing software (MGViewer V1.1.1, MetapleBio Inc.). The results demonstrated successful CBD patency identification in all cases. Mobile GBM showed partial gallbladder visibility, whereas immobile GBM showed limited visibility. Additionally, insights into the adequate visualization of the remaining extrahepatic biliary tree anatomy were provided, extending beyond the assessment of CBD patency and gallbladder intensity. Our study demonstrates the potential of fluorescent IOC using intravenous injection of ICG for assessing the patency of the cystic duct and common bile duct during cholecystectomy in patients with GBM, eliminating the need for surgical catheterization and flushing of the biliary ducts. Further research is warranted to investigate and validate the broader applicability of ICG cholangiography in veterinary medicine.
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Affiliation(s)
- Su-Hyeon Kim
- Department of Veterinary Surgery, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, South Korea
- Department of Veterinary Surgery, Heamaru Referral Hospital, Seongnam, Korea
| | - Sungin Lee
- Department of Veterinary Surgery, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, South Korea
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Brollo PP, Bresadola V. Enhancing visualization and guidance in general surgery: a comprehensive and narrative review of the current cutting-edge technologies and future perspectives. J Gastrointest Surg 2024; 28:179-185. [PMID: 38445941 DOI: 10.1016/j.gassur.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 11/25/2023] [Accepted: 12/08/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND In the last decade, there has been a great effort in developing new technologies to enhance surgical visualization and guidance. This comprehensive and narrative review aimed to provide a wide and extensive overview of the current state of the art on this topic and their near-future perspectives linked to the development of artificial intelligence (AI), by focusing on the most recent and relevant literature. METHODS A comprehensive and narrative review of the literature was performed by searching specific terms on PubMed/MEDLINE, Scopus, and Embase databases, assessing the current state of the art on this topic. RESULTS Fluorescence-guided surgery, contrast-enhanced ultrasound (CEUS), ultra-high frequency ultrasound (UHFUS), photoacoustic imaging (PAI), and augmented reality (AR) are boosting the field of image-guided techniques as the rapid development of AI in surgery is promising a more automated decision-making and surgical movements in the operating room. CONCLUSION Fluorescence-guided surgery, CEUS, UHFUS, PAI, and AR are becoming crucial to give surgeons a new level of information during the intervention, with the right timing and sequence, and represent the future of surgery. As many more controlled studies are needed to validate the employment of these technologies, the next generation of surgeons must become more familiar with the basics of AI to better incorporate new tools into the daily surgical practice of the future.
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Affiliation(s)
- Pier Paolo Brollo
- Department of Medicine, General Surgery Department and Simulation Center, Academic Hospital of Udine, University of Udine, Udine, Italy; General Surgical Oncology Department, Istituto di Ricovero e Cura a Carattere Scientifico Centro di Riferimento Oncologico di Aviano (Istituto Nazionale Tumori), Aviano, Italy.
| | - Vittorio Bresadola
- Department of Medicine, General Surgery Department and Simulation Center, Academic Hospital of Udine, University of Udine, Udine, Italy
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Kim S, Lee CM, Lee Y, Han HJ, Song TJ. Laparoscopic fluorescence imaging technique for visualizing biliary structures using sodium fluorescein: the result of a preclinical study in a porcine model. Ann Surg Treat Res 2023; 104:144-149. [PMID: 36910560 PMCID: PMC9998959 DOI: 10.4174/astr.2023.104.3.144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/17/2023] [Accepted: 02/05/2023] [Indexed: 03/09/2023] Open
Abstract
Purpose Near-infrared fluorescence imaging has been recently applied in the field of hepatobiliary surgery. Our objective was to apply blue-light fluorescence cholangiography during laparoscopic surgery. Therefore, we designed a preclinical study to evaluate the feasibility of using blue-light fluorescence for cholangiography in a porcine model. Methods Five millimeters of sodium fluorescein (SF) solution was administered into the gallbladder of 20 male 3-way crossbred (Landrace × Yorkshire × Duroc) pigs in laparoscopic approach. The biliary tree was observed under blue light (a peak wavelength of 450 nm) emitted from a commercialized light-emitting diode (LED) light source (XLS1 extreme, Chammed). Results In 18 of 20 porcine models, immediately after SF solution was administered into the gallbladder, it was possible to visualize the biliary tree under blue light emitted from the LED light source. Conclusion This study provided a preclinical basis for using blue-light fluorescence cholangiography using SF in laparoscopic surgery. The clinical feasibility of blue-light fluorescence imaging techniques for laparoscopic cholecystectomy remained to be demonstrated.
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Affiliation(s)
- Sungho Kim
- Department of Surgery, Korea University Ansan Hospital, Ansan, Korea
| | - Chang Min Lee
- Department of Surgery, Korea University Ansan Hospital, Ansan, Korea.,Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Yoontaek Lee
- Department of Surgery, Korea University Ansan Hospital, Ansan, Korea
| | - Hyung-Joon Han
- Department of Surgery, Korea University Ansan Hospital, Ansan, Korea.,Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Tae-Jin Song
- Department of Surgery, Korea University Ansan Hospital, Ansan, Korea.,Department of Surgery, Korea University College of Medicine, Seoul, Korea
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She WH, Cheung TT, Chan MY, Chu KW, Ma KW, Tsang SHY, Dai WC, Chan ACY, Lo CM. Routine use of ICG to enhance operative safety in emergency laparoscopic cholecystectomy: a randomized controlled trial. Surg Endosc 2022; 36:4442-4451. [PMID: 35194663 DOI: 10.1007/s00464-021-08795-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 10/17/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To test the hypothesis that ICG fluorescence cholangiography (ICG-FC) helps to identify critical structures during laparoscopic cholecystectomy (LC) and hence reduce biliary injuries and conversions. In LC, biliary injury and conversion often happen if the biliary anatomy is misidentified. METHODS This was a single-center randomized controlled trial from 2017 to 2019. Patients with acute cholecystitis requiring LC were assessed for eligibility for the trial. Patients in the trial were randomized to undergo either conventional LC (conventional arm) or LC with ICG-FC (ICG arm). Conversion rate and biliary injury incidence were outcome measures. RESULTS Totally 92 patients participated (46 patients in each arm). The median age was 61 years in both arms (p = 0.472). The conventional arm had 22 men and 24 women; the ICG arm had 24 men and 22 women (p = 0.677). The two arms were comparable in all perioperative parameters. The time from ICG injection to surgery was 67 (16-1150) min. Both arms had an 8.7% conversion rate (p = 1.000). The median operative time was 140.5 min in the conventional arm and 149.5 min in the ICG arm (p = 0.086). The complication rate was 15.2% in the former and 10.9% in the latter (p = 0.536), and both had a 2.2% bile leakage rate. The median hospital stay was 3.5d in the former and 4.0d in the latter (p = 0.380). CONCLUSION ICG-FC did not make any difference in conversion or complication rate. Its routine use in LC is questionable. However, it may be helpful in difficult cholecystectomies and may be used as an adjunct. TRIAL REGISTRATION The trial was registered with the Institutional Review Board of University of Hong Kong/Hospital Authority Hong Kong West Cluster ( http://www.med.hku.hk/en/research/ethics-and-integrity/human-ethics ). Registration number: UW17-492.
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Affiliation(s)
- Wong Hoi She
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Tan To Cheung
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China.
| | - Miu Yee Chan
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Ka Wan Chu
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Ka Wing Ma
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Simon H Y Tsang
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Wing Chiu Dai
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Albert C Y Chan
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Chung Mau Lo
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
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Utsunomiya T, Sakamoto K, Sogabe K, Takenaka R, Hayashi T, Ogura F, Yamamoto H, Ishida N, Nakamura T, Sakamoto A, Iwata M, Ito C, Matsui T, Nishi Y, Shine M, Uraoka M, Nagaoka T, Tamura K, Funamizu N, Ogawa K, Takada Y. Laparoscopic remnant cholecystectomy for calculi in the remnant gallbladder following subtotal-cholecystectomy: a report of two cases. Surg Case Rep 2021; 7:250. [PMID: 34843016 PMCID: PMC8630207 DOI: 10.1186/s40792-021-01333-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 11/18/2021] [Indexed: 11/10/2022] Open
Abstract
Two cases of laparoscopic remnant cholecystectomy using near-infrared fluorescence cholangiography (NIFC) for remnant gallbladder calculi following subtotal-cholecystectomy are reported. Case 1: a 36-year-old woman was referred to our hospital with acute abdomen. Computed tomography showed remnant gallbladder calculi, with detected no other findings as the cause of the abdominal pain. For intraoperative exploration of the biliary anatomy, 0.25 mg/kg of indocyanine green (ICG) was administered intravenously the day before the operation. NIFC clearly showed the common bile duct and enabled safe laparoscopic remnant cholecystectomy. She was free from symptoms after the operation. Case 2: a 40-year-old woman was referred to our hospital with epigastralgia due to remnant gallbladder calculi after open cholecystectomy. ICG was administered intravenously the day before the operation. Severe adhesions were observed in the upper abdominal cavity and there was tight adherence of the duodenum to the remnant gallbladder. NIFC showed a clear margin that appeared to be the margin between the duodenum and remnant gallbladder. However, dissection of the margin observed by NIFC caused perforation of the duodenum. The clear margin seen with NIFC was likely due to visualization of the gallbladder through the duodenum. Although NIFC is a useful modality for confirming the intraoperative biliary anatomy, it is important not to rely too heavily on NIFC alone, which may lead to misinterpretation of the anatomy.
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Affiliation(s)
- Takeshi Utsunomiya
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan. .,Department of Surgery, Uwajima City Hospital, 1-1 Gotenmachi, Ehime, 798-8510, Japan.
| | - Katsunori Sakamoto
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Kyousei Sogabe
- Department of Surgery, Uwajima City Hospital, 1-1 Gotenmachi, Ehime, 798-8510, Japan
| | - Ryoichi Takenaka
- Department of Surgery, Uwajima City Hospital, 1-1 Gotenmachi, Ehime, 798-8510, Japan
| | - Tatsuya Hayashi
- Department of Surgery, Uwajima City Hospital, 1-1 Gotenmachi, Ehime, 798-8510, Japan
| | - Fumiya Ogura
- Department of Surgery, Seiyo Municipal Hospital, 147-1 Nagaosa, Uwa town, Seiyo, Ehime, 797-0029, Japan
| | - Hisato Yamamoto
- Department of Surgery, Uwajima City Hospital, 1-1 Gotenmachi, Ehime, 798-8510, Japan
| | - Naoki Ishida
- Department of Surgery, Uwajima City Hospital, 1-1 Gotenmachi, Ehime, 798-8510, Japan
| | - Taro Nakamura
- Department of Surgery, Uwajima City Hospital, 1-1 Gotenmachi, Ehime, 798-8510, Japan
| | - Akimasa Sakamoto
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Miku Iwata
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Chihiro Ito
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Takashi Matsui
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Yusuke Nishi
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Mikiya Shine
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Mio Uraoka
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Tomoyuki Nagaoka
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Kei Tamura
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Naotake Funamizu
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Kohei Ogawa
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Yasutsugu Takada
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
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9
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Wang C, Peng W, Yang J, Li Y, Yang J, Hu X, Xia L, Zhang L, Zhong Y, Qiao L, Pan W. Application of near-infrared fluorescent cholangiography using indocyanine green in laparoscopic cholecystectomy. J Int Med Res 2021; 48:300060520979224. [PMID: 33334212 PMCID: PMC7750833 DOI: 10.1177/0300060520979224] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Near-infrared fluorescence cholangiography (NIRF-C) can help to identify the bile duct during laparoscopic cholecystectomy. This retrospective study was performed to investigate the effect of NIRF-C in laparoscopic cholecystectomy. METHODS Consecutive patients who underwent NIRF-C-assisted laparoscopic cholecystectomy (n = 34) or conventional laparoscopic cholecystectomy (n = 36) were enrolled in this study. Identification of biliary structures, the operation time, intraoperative blood loss, and postoperative complications were analyzed. RESULTS Laparoscopic cholecystectomy was completed in all patients without conversion to laparotomy. The median operation time and intraoperative blood loss were not significantly different between the two groups. No intraoperative injuries or postoperative complications occurred in either group. In the NIRF-C group, the visualization rate of the cystic duct, common bile duct, and common hepatic duct prior to dissection was 91%, 79%, and 53%, respectively. The success rate of cholangiography was 100% in the NIRF-C group. NIRF-C was more effective for visualizing biliary structures in patients with a BMI of <25 than >25 kg/m2. CONCLUSIONS NIRF-C is a safe and effective technique that enables real-time identification of the biliary anatomy during laparoscopic cholecystectomy. NIRF-C helps to improve the efficiency of dissection.
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Affiliation(s)
- Chusi Wang
- Department of Biliary-Pancreatic Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Department of Hepatobiliary Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenguang Peng
- Department of Biliary-Pancreatic Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiarui Yang
- Department of Biliary-Pancreatic Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuxuan Li
- Department of Biliary-Pancreatic Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiawei Yang
- Department of Biliary-Pancreatic Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xueqiao Hu
- Department of Biliary-Pancreatic Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Long Xia
- Department of Hepatic Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lei Zhang
- Department of Biliary-Pancreatic Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuesi Zhong
- Department of Hepatobiliary Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Liang Qiao
- Storr Liver Centre, Westmead Institute for Medical Research, University of Sydney at Westmead Hospital, Westmead, NSW, Australia
| | - Weidong Pan
- Department of Biliary-Pancreatic Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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10
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Matsumura M, Kawaguchi Y, Kobayashi Y, Kobayashi K, Ishizawa T, Akamatsu N, Kaneko J, Arita J, Kokudo N, Hasegawa K. Indocyanine green administration a day before surgery may increase bile duct detectability on fluorescence cholangiography during laparoscopic cholecystectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 28:202-210. [PMID: 33091224 DOI: 10.1002/jhbp.855] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/09/2020] [Accepted: 10/09/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND The optimal indocyanine green (ICG) administration protocol for fluorescence cholangiography during laparoscopic cholecystectomy (LC) has yet to be determined. METHODS A prospective study including 20 cases of ICG fluorescence-navigated LC was conducted. Accordingly, the first 10 patients were administered 2.5 mg of ICG on the day of surgery after intubation (surgery-day group), while the remaining 10 consecutive patients were administered 0.25 mg/kg of ICG on the evening before surgery (one-day-before group). Fluorescence intensity (FI) of each tissue and FI ratios were then compared between both groups. RESULTS The median interval between observation and ICG administration was 27 minutes and 16 hours 24 minutes in the surgery-day and one-day-before group, respectively. Although FI values for the common bile duct (CBD), liver, and hepatoduodenal ligament (HDL) were significantly lower in the one-day-before group than in the surgery-day group, CBD- , 0.6-1.2 vs 2.5, 0.9 = -4.8; P < .001), and CBD-HDL contrast (1.7, 1.4-2.4 vs 2.3, 1.5-13.3; P = .038) were significantly higher in the one-day-before group than in the surgery-day group. CONCLUSION ICG administration a day before LC may offer better CBD background contrast compared to administration just prior to surgery.
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Affiliation(s)
- Masaru Matsumura
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshikuni Kawaguchi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yuta Kobayashi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kosuke Kobayashi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeaki Ishizawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Kaneko
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Arita
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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11
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Lwin TM, Hoffman RM, Bouvet M. Fluorescence-guided hepatobiliary surgery with long and short wavelength fluorophores. Hepatobiliary Surg Nutr 2020; 9:615-639. [PMID: 33163512 DOI: 10.21037/hbsn.2019.09.13] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Fluorescence-guided surgery (FGS) is a potentially powerful tool for hepatobiliary (HPB) surgery. The high sensitivity of fluorescence navigation is especially useful in settings where tactile feedback is limited. Objective The present narrative review evaluates literature on the use of FDA-approved fluorophores such as methylene blue (MB), 5-aminolevulinic acid (5-ALA), and indocyanine green (ICG) for clinical intra-operative image-guidance during HPB surgery. Evidence Review Approaches such as dosing, timing, imaging devices and comparative endpoints are summarized. The feasibility and safety of fluorophores in visualizing the biliary tree, identify biliary leaks, outline anatomic hepatic segments, identify tumors, and evaluate perfusion and graft function in liver transplants are discussed. Findings Tumor-specific probes are a promising advancement in FGS with a greater degree of specificity. The current status of tumor-specific probes being evaluated in clinical trials are summarized. Conclusions and Relevance for Reviews Relevant discussion of promising tumor-specific probes in pre-clinical development are discussed. Fluorescence-guidance in HPB surgery is relatively new, but current literature shows that the dyes are reliably able to outline desired structures with a variety of dosing, timing, and imaging devices to provide real-time intra-operative anatomic information to surgeons. Development of tumor-specific probes will further advance the field of HPB surgery especially during oncologic resections.
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Affiliation(s)
- Thinzar M Lwin
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Robert M Hoffman
- Department of Surgery, University of California San Diego, San Diego, CA, USA.,AntiCancer, Inc., San Diego, CA, USA.,VA San Diego Healthcare System, San Diego, CA, USA
| | - Michael Bouvet
- Department of Surgery, University of California San Diego, San Diego, CA, USA.,VA San Diego Healthcare System, San Diego, CA, USA
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12
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Agnus V, Pesce A, Boni L, Van Den Bos J, Morales-Conde S, Paganini AM, Quaresima S, Balla A, La Greca G, Plaudis H, Moretto G, Castagnola M, Santi C, Casali L, Tartamella L, Saadi A, Picchetto A, Arezzo A, Marescaux J, Diana M. Fluorescence-based cholangiography: preliminary results from the IHU-IRCAD-EAES EURO-FIGS registry. Surg Endosc 2020; 34:3888-3896. [PMID: 31591654 DOI: 10.1007/s00464-019-07157-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 09/24/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Near-infrared fluorescence cholangiography (NIRF-C) is a popular application of fluorescence image-guided surgery (FIGS). NIRF-C requires near-infrared optimized laparoscopes and the injection of a fluorophore, most frequently Indocyanine Green (ICG), to highlight the biliary anatomy. It is investigated as a tool to increase safety during cholecystectomy. The European registry on FIGS (EURO-FIGS: www.euro-figs.eu ) aims to obtain a snapshot of the current practices of FIGS across Europe. Data on NIRF-C are presented. METHODS EURO-FIGS is a secured online database which collects anonymized data on surgical procedures performed using FIGS. Data collected for NIRF-C include gender, age, Body Mass Index (BMI), pathology, NIR device, ICG dose, ICG timing of administration before intraoperative visualization, visualization (Y/N) of biliary structures such as the cystic duct (CD), the common bile duct (CBD), the CD-CBD junction, the common hepatic duct (CHD), Visualization scores, adverse reactions to ICG, operative time, and surgical complications. RESULTS Fifteen surgeons (12 European surgical centers) uploaded 314 cases of NIRF-C during cholecystectomy (cholelithiasis n = 249, cholecystitis n = 58, polyps n = 7), using 4 different NIR devices. ICG doses (mg/kg) varied largely (mean 0.28 ± 0.17, median 0.3, range: 0.02-0.62). Similarly, injection-to-visualization timing (minutes) varied largely (mean 217 ± 357; median 57), ranging from 1 min (direct intragallbladder injection in 2 cases) to 3120 min (n = 2 cases). Visualization scores before dissection were significantly correlated, at univariate analysis, with ICG timing (all structures), ICG dose (CD-CBD), device (CD and CD-CBD), surgeon (CD and CD-CBD), and pathology (CD and CD-CBD). BMI was not correlated. At multivariate analysis, pathology and timing remained significant factors affecting the visualization scores of all three structures, whereas ICG dose remained correlated with HD visualization only. CONCLUSIONS The EURO-FIGS registry has confirmed a wide disparity in ICG dose and timing in NIRF-C. EURO-FIGS can represent a valuable tool to promote and monitor FIGS-related educational and consensus activities in Europe.
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Affiliation(s)
- Vincent Agnus
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
| | - Antonio Pesce
- Department of Medical Surgical Sciences and Advanced Technologies "Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Luigi Boni
- Department of Surgery, IRCCS - Ca' Granda - University Hospital of Milan, Milan, Italy
| | - Jacqueline Van Den Bos
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Salvador Morales-Conde
- Unit of Innovation in Minimally Invasive Surgery, Department of General and Digestive Surgery, University Hospital "Virgen del Rocio", University of Seville, Seville, Spain
| | - Alessandro M Paganini
- Obesity and Minimally Invasive Surgery Division, Department of Cardiothoracic, Vascular Surgery, and Organ Transplantation, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Silvia Quaresima
- Obesity and Minimally Invasive Surgery Division, Department of Cardiothoracic, Vascular Surgery, and Organ Transplantation, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Andrea Balla
- Obesity and Minimally Invasive Surgery Division, Department of Cardiothoracic, Vascular Surgery, and Organ Transplantation, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Gaetano La Greca
- Department of Medical Surgical Sciences and Advanced Technologies "Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Haralds Plaudis
- Department of General and Emergency Surgery, Riga East Clinical University Hospital "Gailezers", Riga, Latvia
| | - Gianluigi Moretto
- Department of General Surgery, Ospedale Pederzoli, Peschiera del Garda, Verona, Italy
| | | | - Caterina Santi
- Azienda Unità Sanitaria Locale di Parma, Ospedale di Fidenza, Parma, Italy
| | - Lorenzo Casali
- Azienda Unità Sanitaria Locale di Parma, Ospedale di Fidenza, Parma, Italy
| | - Luciano Tartamella
- Azienda Unità Sanitaria Locale di Parma, Ospedale di Fidenza, Parma, Italy
| | - Alend Saadi
- Department of General Surgery, Hospital of Pourtalès, Neuchâtel, Switzerland
| | - Andrea Picchetto
- General and Colorectal Surgery Division, Department of Cardiothoracic, Vascular Surgery and Organ Transplantation, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - Jacques Marescaux
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
- IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg, France
| | - Michele Diana
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.
- Department of General Surgery, Hospital of Pourtalès, Neuchâtel, Switzerland.
- IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg, France.
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13
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Lehrskov LL, Westen M, Larsen SS, Jensen AB, Kristensen BB, Bisgaard T. Fluorescence or X-ray cholangiography in elective laparoscopic cholecystectomy: a randomized clinical trial. Br J Surg 2020; 107:655-661. [PMID: 32057103 DOI: 10.1002/bjs.11510] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/25/2019] [Accepted: 12/16/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Safe laparoscopic cholecystectomy may necessitate biliary imaging, and non-invasive fluorescence cholangiography may have advantages over contrast X-ray cholangiography. This trial compared fluorescence and X-ray cholangiography for visualization of the critical junction between the cystic, common hepatic and common bile ducts. METHODS This non-inferiority blinded RCT included patients who had either intraoperative fluorescence cholangiography using 0·05 mg/kg indocyanine green or X-ray cholangiography during elective laparoscopic cholecystectomy. RESULTS Between March 2015 and August 2018, a total of 120 patients were randomized (60 in each group). There were no drop-outs and 30-day follow-up data were available for all patients. In intention-to-treat analysis, there was no difference between the fluorescence and X-ray cholangiography groups in ability to visualize the critical junction (49 of 60 versus 51 of 60 respectively; P = 0·230). Fluorescence cholangiography was faster by a few minutes: median 2·0 (range 0·5-5·0) versus 4·8 (1·3-17·6) min (P < 0·001). CONCLUSION Fluorescence cholangiography was confirmed to be non-inferior to X-ray cholangiography in visualizing the critical junction during laparoscopic cholecystectomy. Registration number: NCT02344654 ( http://www.clinicaltrials.gov).
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Affiliation(s)
- L L Lehrskov
- Gastrounit, Surgical Section, Centre for Surgical Research, Hvidovre Hospital, University of Copenhagen, Køge, Denmark
| | - M Westen
- Gastrounit, Surgical Section, Køge, Denmark
| | - S S Larsen
- Gastrounit, Surgical Section, Køge, Denmark
| | | | - B B Kristensen
- Ambulatory Surgery Department, Hvidovre Hospital, Hvidovre, Denmark
| | - T Bisgaard
- Surgical Department, Zealand University Hospital, Køge, Denmark
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14
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Abstract
This article demonstrates surgical techniques of intraoperative fluorescence imaging using indocyanine green, focusing on its application in minimally invasive hepatobiliary and pancreatic surgery. In this area, indocyanine green fluorescence imaging has been applied to liver cancer identification, fluorescence cholangiography, delineation of hepatic segments, and fluorescence angiography and perfusion assessment. The development of target-specific fluorophores and advances in imaging technology will allow real-time intraoperative fluorescence imaging to develop into an essential intraoperative navigation tool. This property may contribute to enhancing both accuracy and safety of minimally invasive surgery.
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Affiliation(s)
- Takeaki Ishizawa
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8655, Japan.
| | - Akio Saiura
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8655, Japan
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15
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van Manen L, Handgraaf HJM, Diana M, Dijkstra J, Ishizawa T, Vahrmeijer AL, Mieog JSD. A practical guide for the use of indocyanine green and methylene blue in fluorescence-guided abdominal surgery. J Surg Oncol 2018; 118:283-300. [PMID: 29938401 PMCID: PMC6175214 DOI: 10.1002/jso.25105] [Citation(s) in RCA: 198] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 04/21/2018] [Indexed: 12/14/2022]
Abstract
Near-infrared (NIR) fluorescence imaging is gaining clinical acceptance over the last years and has been used for detection of lymph nodes, several tumor types, vital structures and tissue perfusion. This review focuses on NIR fluorescence imaging with indocyanine green and methylene blue for different clinical applications in abdominal surgery with an emphasis on oncology, based on a systematic literature search. Furthermore, practical information on doses, injection times, and intraoperative use are provided.
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Affiliation(s)
- Labrinus van Manen
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Michele Diana
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,IRCAD, Research Institute against Cancer of the Digestive System, Strasbourg, France.,Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - Jouke Dijkstra
- Division of Image Processing, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Takeaki Ishizawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | | | - Jan Sven David Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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16
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Pesce A, Latteri S, Barchitta M, Portale TR, Di Stefano B, Agodi A, Russello D, Puleo S, La Greca G. Near-infrared fluorescent cholangiography - real-time visualization of the biliary tree during elective laparoscopic cholecystectomy. HPB (Oxford) 2018; 20:538-545. [PMID: 29292071 DOI: 10.1016/j.hpb.2017.11.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 10/23/2017] [Accepted: 11/30/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose was to evaluate the efficacy of near-infrared fluorescent cholangiography (FC) in real-time visualization of the biliary tree during elective laparoscopic cholecystectomy. METHODS Fifty consecutive elective laparoscopic cholecystectomies were performed with fluorescent cholangiography. FC was performed at three time points: following exposure of Calot's triangle, prior to any dissection; and after partial and complete dissection of Calot's triangle. RESULTS The cystic duct (CD) was identified successfully by FC in 43 of 50 patients (86%) and in 45 of 50 patients (90%) before and after Calot's dissection respectively (p > 0.05). The common hepatic duct (CHD) and the common bile duct (CBD) were identified successfully in 12 of 50 patients (24%) and in 33 of 50 patients (66%) before Calot's dissection respectively and in 26 of 50 patients (52%) and in 47 of 50 patients (94%) after complete Calot's dissection (p = 0.007 and p = 0.001, respectively). Significant differences were observed for CBD visualization rate, in relation to BMI after Calot's dissection (p < 0.05) and history of cholecystitis, before Calot's dissection (p = 0.017). No bile duct injuries were reported. CONCLUSION Fluorescent cholangiography can be considered as a useful tool for intra-operative visualization of the biliary tree during laparoscopic cholecystectomies.
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Affiliation(s)
- Antonio Pesce
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, Via S. Sofia 84, 95123 Catania, Italy.
| | - Saverio Latteri
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, Via S. Sofia 84, 95123 Catania, Italy
| | - Martina Barchitta
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, Via S. Sofia 84, 95123 Catania, Italy
| | - Teresa R Portale
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, Via S. Sofia 84, 95123 Catania, Italy
| | - Biagio Di Stefano
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, Via S. Sofia 84, 95123 Catania, Italy
| | - Antonella Agodi
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, Via S. Sofia 84, 95123 Catania, Italy
| | - Domenico Russello
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, Via S. Sofia 84, 95123 Catania, Italy
| | - Stefano Puleo
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, Via S. Sofia 84, 95123 Catania, Italy
| | - Gaetano La Greca
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, Via S. Sofia 84, 95123 Catania, Italy
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17
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van den Bos J, Wieringa FP, Bouvy ND, Stassen LPS. Optimizing the image of fluorescence cholangiography using ICG: a systematic review and ex vivo experiments. Surg Endosc 2018; 32:4820-4832. [PMID: 29777357 PMCID: PMC6208701 DOI: 10.1007/s00464-018-6233-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 05/09/2018] [Indexed: 12/28/2022]
Abstract
Background Though often only briefly described in the literature, there are clearly factors that have an influence on the fluorescence intensity, and thereby the usefulness of the technique. This article aims to provide an overview of the factors influencing the fluorescence intensity of fluorescence imaging with Indocyanine green, primarily focussed on NIRF guided cholangiography. Methods A systematic search was conducted to gain an overview of currently used methods in NIRF imaging in laparoscopic cholecystectomies. Relevant literature was searched to gain advice on what methods to use. Ex vivo experiments were performed to assess various factors that influence fluorescence intensity and whether the found clinical advices can be confirmed. Results ICG is currently the most widely applied fluorescent dye. Optimal ICG concentration lies between 0.00195 and 0.025 mg/ml, and this dose should be given as early as achievable—but maximum 24 h—before surgery. When holding the laparoscope closer and perpendicular to the dye, the signal is most intense. In patients with a higher BMI and/or cholecystitis, fluorescence intensity is lower, but NIRF seems to be more helpful. There are differences between various marketed fluorescence systems. Also, no uniform method to assess fluorescence intensity is available yet. Conclusions This study identified and discussed several factors that influence the signal of fluorescence cholangiography. These factors should be taken into account when using NIRF cholangiography. Also, surgeons should be aware of new dyes and clinical systems, in order to benefit most from the potential of NIRF imaging. Electronic supplementary material The online version of this article (10.1007/s00464-018-6233-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jacqueline van den Bos
- Department of Surgery, Maastricht University Medical Center, PO box 616, 6200 MD, Maastricht, The Netherlands. .,School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands.
| | - Fokko P Wieringa
- Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,imec the Netherlands, Eindhoven, The Netherlands
| | - Nicole D Bouvy
- Department of Surgery, Maastricht University Medical Center, PO box 616, 6200 MD, Maastricht, The Netherlands.,School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Center, PO box 616, 6200 MD, Maastricht, The Netherlands.,School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
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18
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Wilhelm D, Vogel T, Ostler D, Marahrens N, Kohn N, Koller S, Friess H, Kranzfelder M. Enhanced Visualization: From Intraoperative Tissue Differentiation to Augmented Reality. Visc Med 2018; 34:52-59. [PMID: 29594170 DOI: 10.1159/000485940] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Optimal visualization of the operative field and methods that additionally provide supportive optical information form the basis for target-directed and successful surgery. This article strives to give an overview of current enhanced visualization techniques in visceral surgery and to highlight future developments. Methods The article was written as a comprehensive review on this topic and is based on a MEDLINE search and ongoing research from our own group and from other working groups. Results Various techniques for enhanced visualization are described comprising augmented reality, unspecific and targeted staining methods, and optical modalities such as narrow-band imaging. All facilitate our surgical performance; however, due to missing randomized controlled studies for most of the innovations reported on, the available evidence is low. Conclusion Many new visualization technologies are emerging with the aim to improve our perception of the surgical field leading to less invasive, target-oriented, and elegant treatment forms that are of significant benefit to our patients.
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Affiliation(s)
- Dirk Wilhelm
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Working Group for Minimally Invasive Interdisciplinary Therapeutical Intervention, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Thomas Vogel
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Working Group for Minimally Invasive Interdisciplinary Therapeutical Intervention, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Daniel Ostler
- Working Group for Minimally Invasive Interdisciplinary Therapeutical Intervention, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Nils Marahrens
- Working Group for Minimally Invasive Interdisciplinary Therapeutical Intervention, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Nils Kohn
- Working Group for Minimally Invasive Interdisciplinary Therapeutical Intervention, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sebastian Koller
- Working Group for Minimally Invasive Interdisciplinary Therapeutical Intervention, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Kranzfelder
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Working Group for Minimally Invasive Interdisciplinary Therapeutical Intervention, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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19
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Yoon SY, Lee CM, Song TJ, Han HJ, Kim S. A new fluorescence imaging technique for visualizing hepatobiliary structures using sodium fluorescein: result of a preclinical study in a rat model. Surg Endosc 2017; 32:2076-2083. [PMID: 29067576 DOI: 10.1007/s00464-017-5904-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 09/17/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Near-infrared fluorescence imaging has been recently applied in the field of hepatobiliary surgery. Our objective was to apply blue light fluorescence imaging to cholangiography and liver mapping during laparoscopic surgery. Therefore, we designed a preclinical study to evaluate the feasibility of using blue light fluorescence for cholangiography and liver mapping in a rat model. METHODS Sodium fluorescein solution (1 mL to each individual) were administered intravenously to 20 male Sprague-Dawley rats (6 weeks old, 200-250 g), after laparotomy. Whole abdominal organs were observed under blue light (at a wavelength of 440-490 nm) emitted from a commercialized LED curing light. RESULTS Immediately after the tracer solution was administered into the circulatory system of the rat, it was possible to visualize the location of the kidneys and the bile duct under blue light emitted from the light source. The liver was vaguely stained green by the tracer, while the ureters were not. After establishing biliary retention via duct clamping in the left lateral segment of the liver, the green color of the segment became distinct by the tracer, which showed vague coloration following release of the clamp. CONCLUSION We established the preclinical basis for using blue light fluorescence cholangiography and liver mapping in this study. The clinical feasibility of these techniques during laparoscopic cholecystectomy and hepatectomy remained to be demonstrated.
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Affiliation(s)
- Sam-Youl Yoon
- Department of Surgery, Korea University College of Medicine, Seoul, South Korea.,Department of Surgery, Korea University Medical Center Ansan Hospital, Ansan, Gyeonggi-do, South Korea.,Department of Surgery, Hallym University Medical Center, Anyang, Gyeonggi-do, South Korea
| | - Chang Min Lee
- Department of Surgery, Korea University College of Medicine, Seoul, South Korea. .,Department of Surgery, Korea University Medical Center Ansan Hospital, Ansan, Gyeonggi-do, South Korea.
| | - Tae-Jin Song
- Department of Surgery, Korea University College of Medicine, Seoul, South Korea.,Department of Surgery, Korea University Medical Center Ansan Hospital, Ansan, Gyeonggi-do, South Korea
| | - Hyung Joon Han
- Department of Surgery, Korea University College of Medicine, Seoul, South Korea.,Department of Surgery, Korea University Medical Center Ansan Hospital, Ansan, Gyeonggi-do, South Korea
| | - Seonghan Kim
- Department of Anatomy, Inje University College of Medicine, Busan, South Korea
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20
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Prospective Evaluation of Precision Multimodal Gallbladder Surgery Navigation: Virtual Reality, Near-infrared Fluorescence, and X-ray-based Intraoperative Cholangiography. Ann Surg 2017; 266:890-897. [PMID: 28742709 DOI: 10.1097/sla.0000000000002400] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE We aimed to prospectively evaluate NIR-C, VR-AR, and x-ray intraoperative cholangiography (IOC) during robotic cholecystectomy. BACKGROUND Near-infrared cholangiography (NIR-C) provides real-time, radiation-free biliary anatomy enhancement. Three-dimensional virtual reality (VR) biliary anatomy models can be obtained via software manipulation of magnetic resonance cholangiopancreatography, enabling preoperative VR exploration, and intraoperative augmented reality (AR) navigation. METHODS Fifty-eight patients were scheduled for cholecystectomy for gallbladder lithiasis. VR surgical planning was performed on virtual models. At anesthesia induction, indocyanine green was injected intravenously. AR navigation was obtained by overlaying the virtual model onto real-time images. Before and after Calot triangle dissection, NIR-C was obtained by turning the camera to NIR mode. Finally, an IOC was performed. The 3 modality performances were evaluated and image quality was assessed with a Likert-scale questionnaire. RESULTS The three-dimensional VR planning enabled the identification of 12 anatomical variants in 8 patients, of which only 7 were correctly reported by the radiologists (P = 0.037). A dangerous variant identified at VR induced a "fundus first" approach. The cystic-common bile duct junction was visualized before Calot triangle dissection at VR in 100% of cases, at NIR-C in 98.15%, and in 96.15% at IOC.Mean time to obtain relevant images was shorter with NIR-C versus AR (P = 0.008) and versus IOC (P = 0.00000003). Image quality scores were lower with NIR-C versus AR (P = 0.018) and versus IOC (P < 0.0001). CONCLUSIONS This high-tech protocol illustrates the multimodal imaging of biliary anatomy towards precision cholecystectomy. Those visualization techniques could complement to reduce the likelihood of biliary injuries (NCT01881399).
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21
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Boogerd LSF, Handgraaf HJM, Huurman VAL, Lam HD, Mieog JSD, van der Made WJ, van de Velde CJH, Vahrmeijer AL. The Best Approach for Laparoscopic Fluorescence Cholangiography: Overview of the Literature and Optimization of Dose and Dosing Time. Surg Innov 2017; 24:386-396. [PMID: 28457194 PMCID: PMC5505227 DOI: 10.1177/1553350617702311] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Fluorescence cholangiography using indocyanine green (ICG) can enhance orientation of bile duct anatomy during laparoscopic cholecystectomy. To ensure clear discrimination between bile ducts and liver, the fluorescence ratio between both should be sufficient. This ratio is influenced by the ICG dose and timing of fluorescence imaging. We first systematically identified all strategies for fluorescence cholangiography. Second, we aimed to optimize the dose of ICG and dosing time in a prospective clinical trial. METHODS PubMed was searched for clinical trials studying fluorescence cholangiography. Furthermore, 28 patients planned to undergo laparoscopic cholecystectomy were divided into 7 groups, receiving different intravenous doses (5 or 10 mg ICG) at different time points (0.5, 2, 4, 6, or 24 hours prior to surgery). RESULTS The systematic review revealed 27 trials including 1057 patients. The majority of studies used 2.5 mg administered within 1 hour before imaging. Imaging 3 to 24 hours after ICG administration was never studied. The clinical trial demonstrated that the highest bile duct-to-liver ratio was achieved 3 to 7 hours after administration of 5 mg and 5 to 25 hours after administration of 10 mg ICG. Up to 3 hours after administration of 5 mg and up to 5 hours after administration of 10 mg ICG, the liver was equally or more fluorescent than the cystic duct, resulting in a ratio ≤1.0. CONCLUSION This study shows for the first time that the interval between ICG administration and intraoperative fluorescence cholangiography should be extended. Administering 5 mg ICG at least 3 hours before imaging is easy to implement in everyday clinical practice and results in bile duct-to-liver ratios >1.0.
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Affiliation(s)
| | | | | | - Hwai-Ding Lam
- 1 Leiden University Medical Center, Leiden, Netherlands
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22
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Application of Fluorescent Cholangiography for Determination of the Resection Line During a Single-Incision Laparoscopic Cholecystectomy for a Benign Lesion of the Cystic Duct: Preliminary Experience. Surg Laparosc Endosc Percutan Tech 2017; 26:e171-e173. [PMID: 27846167 DOI: 10.1097/sle.0000000000000342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND To avoid bile leakage from the stump of a cystic duct that is closed at edematous and/or involved areas, the decision regarding the location of the resection line during a laparoscopic cholecystectomy for benign lesions extending into the cystic duct is important and requires technical ingenuity. For these situations, we used fluorescent cholangiography. METHODS Our procedure for single-incision laparoscopic cholecystectomy utilized the SILS-Port, and an additional pair of 5-mm forceps was inserted via an umbilical incision. As a fluorescence source, 1 mL of indocyanine green was intravenously injected after endotracheal intubation of patients in the operating room. A laparoscopic fluorescence imaging system developed by Karl Storz Endoskope was utilized for fluorescent cholangiography. RESULTS Fluorescent cholangiography could be used to identify the border of the lesion in the cystic duct. According to the fluorescent cholangiography results, a location for the resection line of the cystic duct could be identified; therefore, the planned resection was successful and produced a histologically negative margin. CONCLUSIONS Application of fluorescent cholangiography in the determination of the location of the resection line location during a laparoscopic cholecystectomy for benign lesions of the cystic duct should be widely accepted.
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23
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Vlek SL, van Dam DA, Rubinstein SM, de Lange-de Klerk ESM, Schoonmade LJ, Tuynman JB, Meijerink WJHJ, Ankersmit M. Biliary tract visualization using near-infrared imaging with indocyanine green during laparoscopic cholecystectomy: results of a systematic review. Surg Endosc 2016; 31:2731-2742. [PMID: 27844236 PMCID: PMC5487840 DOI: 10.1007/s00464-016-5318-7] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 10/25/2016] [Indexed: 12/14/2022]
Abstract
Background Near-infrared imaging with indocyanine green (ICG) has been extensively investigated during laparoscopic cholecystectomy (LC). However, methods vary between studies, especially regarding patient selection, dosage and timing. The aim of this systematic review was to evaluate the potential of the near-infrared imaging technique with ICG to identify biliary structures during LC. Methods A comprehensive systematic literature search was performed. Prospective trials examining the use of ICG during LC were included. Primary outcome was biliary tract visualization. Risk of bias was assessed using ROBINS-I. Secondly, a meta-analysis was performed comparing ICG to intraoperative cholangiography (IOC) for identification of biliary structures. GRADE was used to assess the quality of the evidence. Results Nineteen studies were included. Based upon the pooled data from 13 studies, cystic duct (Lusch et al. in J Endourol 28:261–266, 2014) visualization was 86.5% (95% CI 71.2–96.6%) prior to dissection of Calot’s triangle with a 2.5-mg dosage of ICG and 96.5% (95% CI 93.9–98.4%) after dissection. The results were not appreciably different when the dosage was based upon bodyweight. There is moderate quality evidence that the CD is more frequently visualized using ICG than IOC (RR 1.16; 95% CI 1.00–1.35); however, this difference was not statistically significant. Conclusion This systematic review provides equal results for biliary tract visualization with near-infrared imaging with ICG during LC compared to IOC. Near-infrared imaging with ICG has the potential to replace IOC for biliary mapping. However, methods of near-infrared imaging with ICG vary. Future research is necessary for optimization and standardization of the near-infrared ICG technique. Electronic supplementary material The online version of this article (doi:10.1007/s00464-016-5318-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- S L Vlek
- Department of Surgery, VU University Medical Centre, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands.
| | - D A van Dam
- Department of Surgery, VU University Medical Centre, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - S M Rubinstein
- Epidemiology and Biostatistics, VU University, Amsterdam, The Netherlands
| | | | - L J Schoonmade
- Medical Library, VU University, Amsterdam, The Netherlands
| | - J B Tuynman
- Department of Surgery, VU University Medical Centre, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - W J H J Meijerink
- Department of Surgery, VU University Medical Centre, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - M Ankersmit
- Department of Surgery, VU University Medical Centre, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
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24
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Gangemi A, Danilkowicz R, Elli FE, Bianco F, Masrur M, Giulianotti PC. Could ICG-aided robotic cholecystectomy reduce the rate of open conversion reported with laparoscopic approach? A head to head comparison of the largest single institution studies. J Robot Surg 2016; 11:77-82. [PMID: 27435700 DOI: 10.1007/s11701-016-0624-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 07/11/2016] [Indexed: 01/01/2023]
Abstract
Comparative studies between robotic and laparoscopic cholecystectomy (LC) focus heavily on economic considerations under the assumption of comparable clinical outcomes. Advancement of the robotic technique and the further widespread use of this approach suggest a need for newer comparison studies. 676 ICG-aided robotic cholecystectomies (ICG-aided RC) performed at the University of Illinois at Chicago (UIC) Division of General, Minimally Invasive and Robotic Surgery were compiled retrospectively. Additionally, 289 LC were similarly obtained. Data were compared to the largest single institution LC data sets from within the US and abroad. Statistically significant variations were found between UIC-RC and UIC-LC in minor biliary injuries (p = 0.049), overall open conversion (p ≤ 0.001), open conversion in the acute setting (p = 0.002), and mean blood loss (p < 0.001). UIC-RC open conversions were also significantly lower than Greenville Health System LC (p ≤ 0.001). Additionally, UIC ICG-RC resulted in the lowest percentages of major biliary injuries (0 %) and highest percentage of biliary anomalies identified (2.07 %). ICG-aided cholangiography and the technical advantages associated with the robotic platform may significantly decrease the rate of open conversion in both the acute and non-acute setting. The sample size discrepancy and the non-randomized nature of our study do not allow for drawing definitive conclusions.
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Affiliation(s)
- A Gangemi
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S. Wood Street, Suite 435E, Chicago, IL, 60612, USA.
| | - R Danilkowicz
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S. Wood Street, Suite 435E, Chicago, IL, 60612, USA
| | - F E Elli
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S. Wood Street, Suite 435E, Chicago, IL, 60612, USA
| | - F Bianco
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S. Wood Street, Suite 435E, Chicago, IL, 60612, USA
| | - M Masrur
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S. Wood Street, Suite 435E, Chicago, IL, 60612, USA
| | - P C Giulianotti
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S. Wood Street, Suite 435E, Chicago, IL, 60612, USA
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25
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Igami T, Nojiri M, Shinohara K, Ebata T, Yokoyama Y, Sugawara G, Mizuno T, Yamaguchi J, Nagino M. Clinical value and pitfalls of fluorescent cholangiography during single-incision laparoscopic cholecystectomy. Surg Today 2016; 46:1443-1450. [PMID: 27002714 DOI: 10.1007/s00595-016-1330-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 02/25/2016] [Indexed: 12/16/2022]
Abstract
PURPOSE To clarify the clinical value and pitfalls of fluorescent cholangiography (FC) during single-incision laparoscopic cholecystectomy (SILC). METHODS Our SILC procedure utilized the SILS-Port with additional 5-mm forceps through an umbilical incision. A laparoscopic fluorescent imaging system developed by Karl Storz Endoskope was utilized for fluorescent cholangiography. RESULTS We performed fluorescent cholangiography during SILC in 21 patients. All procedures were completed successfully without biliary injury. The detectability of the running course of the cystic duct, the confluence between the cystic duct and the common hepatic duct, and the common hepatic duct before the dissection in Calot's triangle was 47.6, 71.4, and 81.0 %, respectively. The detectability of biliary structures was worse in 9 obese patients (body mass index ≥ 25.0 kg/m2) than in 12 non-obese patients. The mean operative time for the patients in whom fluorescent cholangiography could identify the running course of the cystic duct before dissection in Calot's triangle (68 ± 16 min) was shorter than that for the other patients (91 ± 35 min; p = 0.037). CONCLUSIONS Fluorescent cholangiography can prevent biliary injury during SILC and facilitate SILC. Obesity is the most important factor that can prevent identification of biliary structures under fluorescent cholangiography.
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Affiliation(s)
- Tsuyoshi Igami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Motoi Nojiri
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Kentaro Shinohara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Gen Sugawara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Takashi Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Junpei Yamaguchi
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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26
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Kawaguchi Y, Ishizawa T, Nagata R, Kaneko J, Sakamoto Y, Aoki T, Sugawara Y, Hasegawa K, Kokudo N. Exclusion criteria for assuring safety of single-incision laparoscopic cholecystectomy. Biosci Trends 2016; 9:407-13. [PMID: 26781799 DOI: 10.5582/bst.2015.01143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite increasing popularity of single-incision laparoscopic cholecystectomy (SILC), indication criteria assuring safety of SILC has yet to be established. In the present study, the subjects consisted of 146 consecutive patients undergoing conventional laparoscopic cholecystectomy (CLC) or SILC. SILC was indicated after excluding patients who met following criteria: age > 75 years, obesity, operative scar, cardiopulmonary diseases, acute cholecystitis, choledocholithiasis and abnormal bile duct anatomy. Thirty-four patients were excluded from the SILC candidates (moderate/high-risk CLC group). Among the 112 potential candidates, SILC was indicated for 23 patients (21%, SILC group) and the remaining 89 patients (79%) underwent CLC (low-risk CLC group). In the SILC group, operation time was longer than in the low-risk CLC group (171 [113-286] vs. 126 [72-240] min, p < 0.01), but the periods requiring painkiller was shorter. That led to reduced length of hospital stay compared to low-risk CLC group (2 [2-4] vs. 4 [2-12] days, p < 0.01). Between the low-risk CLC and moderate/high-risk CLC group, operation time was significantly longer and amount of blood loss was larger in the latter group. No complications were encountered in the SILC group. SILC can be indicated safely as far as appropriate criteria is adopted for excluding patients in whom complicated laparoscopic procedures are needed.
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Affiliation(s)
- Yoshikuni Kawaguchi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo
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27
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Chuang SH, Lin CS. Single-incision laparoscopic surgery for biliary tract disease. World J Gastroenterol 2016; 22:736-747. [PMID: 26811621 PMCID: PMC4716073 DOI: 10.3748/wjg.v22.i2.736] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 09/19/2015] [Accepted: 10/20/2015] [Indexed: 02/06/2023] Open
Abstract
Single-incision laparoscopic surgery (SILS), or laparoendoscopic single-site surgery, has been employed in various fields to minimize traumatic effects over the last two decades. Single-incision laparoscopic cholecystectomy (SILC) has been the most frequently studied SILS to date. Hundreds of studies on SILC have failed to present conclusive results. Most randomized controlled trials (RCTs) have been small in scale and have been conducted under ideal operative conditions. The role of SILC in complicated scenarios remains uncertain. As common bile duct exploration (CBDE) methods have been used for more than one hundred years, laparoscopic CBDE (LCBDE) has emerged as an effective, demanding, and infrequent technique employed during the laparoscopic era. Likewise, laparoscopic biliary-enteric anastomosis is difficult to carry out, with only a few studies have been published on the approach. The application of SILS to CBDE and biliary-enteric anastomosis is extremely rare, and such innovative procedures are only carried out by a number of specialized groups across the globe. Herein we present a thorough and detailed analysis of SILC in terms of operative techniques, training and learning curves, safety and efficacy levels, recovery trends, and costs by reviewing RCTs conducted over the past three years and two recently updated meta-analyses. All existing literature on single-incision LCBDE and single-incision laparoscopic hepaticojejunostomy has been reviewed to describe these two demanding techniques.
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28
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Mohsen A, Elbasiouny MS, El-Shazli M, Azmy O, Amr A. Evaluation of the Effectiveness of Fluorescent Visualization of Bile Ducts Using Fluorescein and Ultraviolet A at Laparoscopic Cholecystectomy. Surg Innov 2015; 23:261-5. [DOI: 10.1177/1553350615610652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. This work studied the diagnostic effectiveness of a new technology and device to augment visualization of bile ducts at laparoscopic cholecystectomy. It depends on excitation of fluorescein in bile by ultraviolet light to get green fluorescent light emanating from these ducts. Methods. Forty laparoscopic cholecystectomy patients received fluorescein sodium injections either in the gallbladder or intravenously, followed by exposure of the expected bile ducts area to ultraviolet light that was delivered by a specially designed device. Neutral observing surgeons were asked to judge whether or not they could see fluorescent bile ducts early in the operation before they were displayed by dissection. Accordingly, specificity, sensitivity, likelihood ratios, and predictive values of the technique were calculated. Results. Fluorescent bile ducts were seen at an earlier stage than their detection by dissection in 33 out of 40 operations. The technique had 100% specificity, 82.5% sensitivity, 0.18 negative likelihood ratio, 100% positive predictive value, and 85.11% negative predictive value. There were no complications related to the technique. Conclusions. The developing ultraviolet/fluorescein technique is helpful in early localization of bile ducts at laparoscopic cholecystectomy. When fluorescence is detected in the field, the technique can be completely relied on to denote the position of bile ducts. In a few cases fluorescence is not detected. Here further development of the device is the need to improve its sensitivity. Otherwise, the technique is quite simple and safe.
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Affiliation(s)
| | | | | | | | - Ahmed Amr
- National Research Center, Cairo, Egypt
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Azagury DE, Dua MM, Barrese JC, Henderson JM, Buchs NC, Ris F, Cloyd JM, Martinie JB, Razzaque S, Nicolau S, Soler L, Marescaux J, Visser BC. Image-guided surgery. Curr Probl Surg 2015; 52:476-520. [PMID: 26683419 DOI: 10.1067/j.cpsurg.2015.10.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 10/01/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Dan E Azagury
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Monica M Dua
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - James C Barrese
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Jaimie M Henderson
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Nicolas C Buchs
- Department of Surgery, University Hospital of Geneva, Clinic for Visceral and Transplantation Surgery, Geneva, Switzerland
| | - Frederic Ris
- Department of Surgery, University Hospital of Geneva, Clinic for Visceral and Transplantation Surgery, Geneva, Switzerland
| | - Jordan M Cloyd
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - John B Martinie
- Department of Surgery, Carolinas Healthcare System, Charlotte, NC
| | - Sharif Razzaque
- Department of Surgery, Carolinas Healthcare System, Charlotte, NC
| | - Stéphane Nicolau
- IRCAD (Research Institute Against Digestive Cancer), Strasbourg, France
| | - Luc Soler
- IRCAD (Research Institute Against Digestive Cancer), Strasbourg, France
| | - Jacques Marescaux
- IRCAD (Research Institute Against Digestive Cancer), Strasbourg, France
| | - Brendan C Visser
- Department of Surgery, Stanford University School of Medicine, Stanford, CA.
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Tanaka M, Inoue Y, Mise Y, Ishizawa T, Arita J, Takahashi Y, Saiura A. Laparoscopic deroofing for polycystic liver disease using laparoscopic fusion indocyanine green fluorescence imaging. Surg Endosc 2015; 30:2620-3. [PMID: 26416378 DOI: 10.1007/s00464-015-4526-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Accepted: 08/13/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND Laparoscopic deroofing is widely used for the treatment of symptomatic polycystic liver disease (PCLD). However, bile leakage is a common complication of surgical management for PCLD. Until now, indocyanine green fluorescence imaging (IGFI) has played an active role in hepatobiliary surgery. Herein, we report the effective application of a laparoscopic fusion IGFI system, known as PINPOINT, for laparoscopic deroofing. METHODS In this study, we performed laparoscopic deroofing for PCLD using the laparoscopic fusion IGFI system. We conducted the procedure mainly under the normal view mode, occasionally switching to the fusion IGFI mode. First, we confirmed that the liver cysts did not contain bile using the fusion IGFI mode and then used a percutaneous puncture needle to remove the fluid from some of the giant cysts. Second, using the fusion IGFI mode, we were able to detect thin biliary branches and to adjust the division line of the cyst wall accordingly or, occasionally, to ligate the branches. Finally, we searched for and identified unexpected small bile leakage and then closed it using sutures. RESULTS The laparoscopic fusion IGFI system can simultaneously show fluorescent images, such as cholangiography and the liver parenchyma, on the normal color view. In the fusion IGFI mode, the intrahepatic bile duct and liver parenchyma can be easily discriminated in real time throughout the procedure. Accordingly, the laparoscopic fusion IGFI system is useful for the surgical treatment of PCLD, in which the boundary between the liver cysts and the liver parenchyma can otherwise be difficult to identify. This technique also enables the branches of Glisson's capsule to be identified without any other intervention. CONCLUSION The novel application of the laparoscopic fusion IGFI system allows reliable navigation for PCLD surgery.
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Affiliation(s)
- Masayuki Tanaka
- Department of HBP Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yosuke Inoue
- Department of HBP Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yoshihiro Mise
- Department of HBP Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takeaki Ishizawa
- Department of HBP Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Junichi Arita
- Department of HBP Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yu Takahashi
- Department of HBP Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akio Saiura
- Department of HBP Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
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Dip F, Nguyen D, Montorfano L, Noste MES, Menzo EL, Simpfendorfer C, Szomstein S, Rosenthal R. Accuracy of Near Infrared-Guided Surgery in Morbidly Obese Subjects Undergoing Laparoscopic Cholecystectomy. Obes Surg 2015. [DOI: 10.1007/s11695-015-1781-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Pesce A, Piccolo G, La Greca G, Puleo S. Utility of fluorescent cholangiography during laparoscopic cholecystectomy: A systematic review. World J Gastroenterol 2015; 21:7877-7883. [PMID: 26167088 PMCID: PMC4491975 DOI: 10.3748/wjg.v21.i25.7877] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 04/16/2015] [Accepted: 05/27/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To verify the utility of fluorescent cholangiography for more rigorous identification of the extrahepatic biliary system.
METHODS: MEDLINE and PubMed searches were performed using the key words “fluorescent cholangiography”, “fluorescent angiography”, “intraoperative fluorescent imaging”, and “laparoscopic cholecystectomy” in order to identify relevant articles published in English, French, German, and Italian during the years of 2009 to 2014. Reference lists from the articles were reviewed to identify additional pertinent articles. For studies published in languages other than those mentioned above, all available information was collected from their English abstracts. Retrieved manuscripts (case reports, reviews, and abstracts) concerning the application of fluorescent cholangiography were reviewed by the authors, and the data were extracted using a standardized collection tool. Data were subsequently analyzed with descriptive statistics. In contrast to classic meta-analyses, statistical analysis was performed where the outcome was calculated as the percentages of an event (without comparison) in pseudo-cohorts of observed patients.
RESULTS: A total of 16 studies were found that involved fluorescent cholangiography during standard laparoscopic cholecystectomies (n = 11), single-incision robotic cholecystectomies (n = 3), multiport robotic cholecystectomy (n = 1), and single-incision laparoscopic cholecystectomy (n = 1). Overall, these preliminary studies indicated that this novel technique was highly sensitive for the detection of important biliary anatomy and could facilitate the prevention of bile duct injuries. The structures effectively identified before dissection of Calot’s triangle included the cystic duct (CD), the common hepatic duct (CHD), the common bile duct (CBD), and the CD-CHD junction. A review of the literature revealed that the frequencies of detection of the extrahepatic biliary system ranged from 71.4% to 100% for the CD, 33.3% to 100% for the CHD, 50% to 100% for the CBD, and 25% to 100% for the CD-CHD junction. However, the frequency of visualization of the CD and the CBD were reduced in patients with a body mass index > 35 kg/m2 relative to those with a body mass index < 35 kg/m2 (91.0% and 64.0% vs 92.3% and 71.8%, respectively).
CONCLUSION: Fluorescent cholangiography is a safe procedure enabling real-time visualization of bile duct anatomy and may become standard practice to prevent bile duct injury during laparoscopic cholecystectomy.
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van Dam DA, Ankersmit M, van de Ven P, van Rijswijk AS, Tuynman JB, Meijerink WJHJ. Comparing Near-Infrared Imaging with Indocyanine Green to Conventional Imaging During Laparoscopic Cholecystectomy: A Prospective Crossover Study. J Laparoendosc Adv Surg Tech A 2015; 25:486-92. [PMID: 25974072 DOI: 10.1089/lap.2014.0248] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The aim of this study was to test and validate a novel noninvasive method for intraoperative visualization of extrahepatic bile ducts during laparoscopic cholecystectomy. Injury to the common bile duct (CBD) is a rare but major complication of laparoscopic cholecystectomy. Most injuries occur when anatomy is unclear due to the presence of anatomic variations, acute inflammation, or adhesions. PATIENTS AND METHODS Thirty patients were included, and each received an intravenous injection of 0.05 mg/kg of indocyanine green (ICG) (ICG-Pulsion(®); PULSION Medical Systems AG, Munich, Germany) prior to the start of surgery. Laparoscopic cholecystectomy was performed according to standard procedures. The CBD and cystic duct (CD) were visualized before and during dissection of the liver hilus using a conventional laparoscopic camera and a recently developed near-infrared (NIR) camera (Olympus, Tokyo, Japan). RESULTS Using ICG-NIR, the CBD and CD could be visualized 11 minutes (P=.008) and 8.6 minutes (P=.001) earlier than with a conventional camera. Both early (20/30 patients) and late (26/30 patients) identification of the CBD with ICG-NIR was significantly more frequent compared with conventional images (2/30 and 10/30, respectively; P<.001). One postoperative bilioma required re-admission and endoscopic retrograde cholangiopancreatography with stent placement. CONCLUSIONS Identification of the CBD and CD using a low dose of ICG and the NIR camera was both faster and more frequent compared with conventional laparoscopic images during elective laparoscopic cholecystectomy.
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Affiliation(s)
- Dieuwertje A van Dam
- 1 Department of Surgery, VU University Medical Centre , Amsterdam, The Netherlands
| | - Marjolein Ankersmit
- 1 Department of Surgery, VU University Medical Centre , Amsterdam, The Netherlands
| | - Peter van de Ven
- 2 Department of Epidemiology, VU University Medical Centre , Amsterdam, The Netherlands
| | | | - Jurriaan B Tuynman
- 1 Department of Surgery, VU University Medical Centre , Amsterdam, The Netherlands
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Marano A, Priora F, Lenti LM, Ravazzoni F, Quarati R, Spinoglio G. Application of fluorescence in robotic general surgery: review of the literature and state of the art. World J Surg 2015; 37:2800-11. [PMID: 23645129 DOI: 10.1007/s00268-013-2066-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The initial use of the indocyanine green fluorescence imaging system was for sentinel lymph node biopsy in patients with breast or colorectal cancer. Since then, application of this method has received wide acceptance in various fields of surgical oncology, and it has become a valid diagnostic tool for guiding cancer treatment. It has also been employed in numerous conventional surgical procedures with much success and benefit to the patient. The advent of minimally invasive surgery brought with it a new use for fluorescence in helping to improve the safety of these procedures, particularly for single-site procedures. In 2010, a near-infrared camera was integrated into the da Vinci Si System, creating a combination of technical and minimally invasive advantages that have been embraced by several experienced surgeons. The use of fluorescence, although useful, is considered challenging. Only a few studies are currently available on the use of fluorescence in robotic general surgery, whereas many articles have focused on its application in open and laparoscopic surgery. Many of these reports describe promising and satisfactory results, although with some shortcomings. The purpose of this article is to review the current status of the use of fluorescence in general surgery and particularly its role in robotic surgery. We also review potential uses in the future.
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Affiliation(s)
- Alessandra Marano
- Department of General and Oncologic Surgery, SS Antonio e Biagio Hospital, Via Venezia 16, 15121, Alessandria, Italy,
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Abstract
Hepatobiliary (HB) surgery is a challenging surgical subspecialty that requires highly specialized training and an adequate level of experience in order to be performed safely. As a result, minimally invasive HB surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant to adopt the approach. Recently development of the robotic platform has provided a tool that can overcome many of the limitations of conventional laparoscopic HB surgery. Augmented dexterity enabled by the endowristed movements, software filtration of the surgeon's movements, and high-definition three-dimensional vision provided by the stereoscopic camera combine to allow steady and careful dissection of the liver hilum structures, as well as prompt and precise endosuturing in cases of intraoperative bleeding. These advantages have fostered many centers to widen the indications for minimally invasive HB and gastric surgery, with encouraging initial results. As one of the surgical groups that has performed the largest number of robot-assisted procedures worldwide, we provide a review of the state of the art in minimally invasive robot-assisted HB surgery.
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Near-Infrared Fluorescence Imaging for Real-Time Intraoperative Anatomical Guidance in Minimally Invasive Surgery: A Systematic Review of the Literature. World J Surg 2014; 39:1069-79. [DOI: 10.1007/s00268-014-2911-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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37
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Verbeek FPR, Schaafsma BE, Tummers QRJG, van der Vorst JR, van der Made WJ, Baeten CIM, Bonsing BA, Frangioni JV, van de Velde CJH, Vahrmeijer AL, Swijnenburg RJ. Optimization of near-infrared fluorescence cholangiography for open and laparoscopic surgery. Surg Endosc 2014; 28:1076-82. [PMID: 24232054 DOI: 10.1007/s00464-013-3305-9] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 08/23/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND During laparoscopic cholecystectomy, common bile duct (CBD) injury is a rare but severe complication. To reduce the risk of injury, near-infrared (NIR) fluorescent cholangiography using indocyanine green (ICG) has recently been introduced as a novel method of visualizing the biliary system during surgery. To date, several studies have shown feasibility of this technique; however, liver background fluorescence remains a major problem during fluorescent cholangiography. The aim of the current study was to optimize ICG dose and timing for NIR cholangiography using a quantitative intraoperative camera system during open hepatopancreatobiliary (HPB) surgery. Subsequently, these results were validated during laparoscopic cholecystectomy using a laparoscopic fluorescence imaging system. METHODS Twenty-seven patients who underwent NIR imaging using the Mini-FLARE image-guided surgery system during open HPB surgery were analyzed to assess optimal dosage and timing of ICG administration. ICG was intravenously injected preoperatively at doses of 5, 10, and 20 mg, and imaged at either 30 min (early) or 24 h (delayed) post-injection. Next, the optimal doses found for early and delayed imaging were applied to two groups of seven patients (n = 14) undergoing laparoscopic NIR fluorescent cholangiography during laparoscopic cholecystectomy. RESULTS Median liver-to-background contrast was 23.5 (range 22.1–35.0), 16.8 (range 11.3–25.1), 1.3 (range 0.7–7.8), and 2.5 (range 1.3–3.6) for 5 mg/30 min, 10 mg/30 min, 10 mg/24 h, and 20 mg/24 h, respectively. Fluorescence intensity of the liver was significantly lower in the 10 mg delayed-imaging dose group compared with the early imaging 5 and 10 mg dose groups (p = 0.001), which resulted in a significant increase in CBD-to-liver contrast ratio compared with the early administration groups (p < 0.002). These findings were qualitatively confirmed during laparoscopic cholecystectomy. CONCLUSION This study shows that a prolonged interval between ICG administration and surgery permits optimal NIR cholangiography with minimal liver background fluorescence.
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Fluorescent imaging of the biliary tract during laparoscopic cholecystectomy. ANNALS OF SURGICAL INNOVATION AND RESEARCH 2014; 8:5. [PMID: 25317203 PMCID: PMC4196113 DOI: 10.1186/s13022-014-0005-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 07/16/2014] [Indexed: 01/28/2023]
Abstract
The introduction of laparoscopic cholecystectomy was associated with increased incidences of bile duct injury. The primary cause appears to be misidentification of the biliary anatomy. Routine intra-operative cholangiography has been recommended to reduce accidental duct injury, although in practice it is more often reserved for selected cases. There has been interest in the use of fluorescent agents excreted via the biliary system to enable real-time intra-operative imaging, to aid the laparoscopic surgeon in correctly interpreting the anatomy. The primary aim of this review is to evaluate the ability of fluorescent cholangiography to identify important biliary anatomy intra-operatively. Secondary aims are to investigate its ability to detect important intra-operative pathology such as bile leaks, identify potential alternative fluorophores, and evaluate the evidence regarding patient outcomes.
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Schnelldorfer T, Jenkins RL, Birkett DH, Georgakoudi I. From shadow to light: visualization of extrahepatic bile ducts using image-enhanced laparoscopy. Surg Innov 2014; 22:194-200. [PMID: 24786338 DOI: 10.1177/1553350614531661] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Correct recognition of the extrahepatic bile ducts is thought to be crucial to reduce the risk of bile duct injuries during various laparoscopic procedures. Image-enhanced laparoscopy techniques, utilizing various optical modalities other than white light, may help in detecting structures "hidden" underneath connective tissue. METHODS A systematic literature search was conducted of studies describing image-enhanced laparoscopy techniques for visualization of the extrahepatic bile ducts. RESULTS In all, 29 articles met inclusion criteria. They describe various techniques in the animal or human setting, including autofluorescence imaging, drug-enhanced fluorescence imaging, infrared thermography, and spectral imaging. This review describes these various techniques and their results. CONCLUSION Image-enhanced laparoscopy techniques for real-time visualization of extrahepatic bile ducts are still in its infancy. Out of the techniques currently described, indocyanine green-enhanced near-infrared fluorescence laparoscopy has the most mature results, but other techniques also appear promising. It can be expected that in the future, image-enhanced laparoscopy might become a routine adjunct to any white-light laparoscopic operation near the hepatic hilum.
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Daskalaki D, Fernandes E, Wang X, Bianco FM, Elli EF, Ayloo S, Masrur M, Milone L, Giulianotti PC. Indocyanine green (ICG) fluorescent cholangiography during robotic cholecystectomy: results of 184 consecutive cases in a single institution. Surg Innov 2014; 21:615-21. [PMID: 24616013 DOI: 10.1177/1553350614524839] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND/AIM Laparoscopic cholecystectomy is currently the gold standard treatment for gallstone disease. Bile duct injury is a rare and severe complication of this procedure, with a reported incidence of 0.4% to 0.8% and is mostly a result of misperception and misinterpretation of the biliary anatomy. Robotic cholecystectomy has proven to be a safe and feasible approach. One of the latest innovations in minimally invasive technology is fluorescent imaging using indocyanine green (ICG). The aim of this study is to evaluate the efficacy of ICG and the Da Vinci Fluorescence Imaging Vision System in real-time visualization of the biliary anatomy. METHODS A total of 184 robotic cholecystectomies with ICG fluorescence cholangiography were performed between July 2011 and February 2013. All patients received a dose of 2.5 mg of ICG 45 minutes prior to the beginning of the surgical procedure. The procedures were multiport or single port depending on the case. RESULTS No conversions to open or laparoscopic surgery occurred in this series. The overall postoperative complication rate was 3.2%. No biliary injuries occurred. ICG fluorescence allowed visualization of at least 1 biliary structure in 99% of cases. The cystic duct, the common bile duct, and the common hepatic duct were successfully visualized with ICG in 97.8%, 96.1%, and 94% of cases, respectively. CONCLUSIONS ICG fluorescent cholangiography during robotic cholecystectomy is a safe and effective procedure that helps real-time visualization of the biliary tree anatomy.
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Affiliation(s)
- Despoina Daskalaki
- University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - Eduardo Fernandes
- University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - Xiaoying Wang
- University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | | | | | - Subashini Ayloo
- University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - Mario Masrur
- University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - Luca Milone
- University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
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Cost analysis and effectiveness comparing the routine use of intraoperative fluorescent cholangiography with fluoroscopic cholangiogram in patients undergoing laparoscopic cholecystectomy. Surg Endosc 2014; 28:1838-43. [PMID: 24414461 DOI: 10.1007/s00464-013-3394-5] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 12/13/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Despite the standardization of laparoscopic cholecystectomy (LC), the rate of bile duct injury (BDI) has risen from 0.2 to 0.5%. Routine use of intraoperative cholangiography (IOC) has not been widely accepted because of its cost and a lack of evidence concerning its use in preventing BDI. Fluorescent cholangiography (FC), which has recently been advocated as an alternative to IOC, is a novel intraoperative procedure involving infrared visualization of the biliary structures. This study evaluated costs and effectiveness of routinely implemented FC and IOC during LC. MATERIALS AND METHODS Between February and June 2013, the authors prospectively collected the data of all patients undergoing laparoscopic cholecystectomy. We retrospectively reviewed and compared the use of FC and IOC. Procedure time, procedure cost, and effectiveness of the two methods were analyzed and compared. The surgeons involved in the cases completed a survey on the usefulness of each method. RESULTS A total of 43 patients (21 males and 22 females) were analyzed during the study period. Mean age was 49.53 ± 14.35 years and mean body mass index was 28.35 ± 8 kg/m(2). Overall mean operative time was 64.95 ± 17.43 min. FC was faster than IOC (0.71 ± 0.26 vs. 7.15 ± 3.76 min; p < 0.0001). FC was successfully performed in 43 of 43 cases (100%) and IOC in 40 of 43 cases (93.02%). FC was less expensive than IOC (US$14.10 ± 4.31 vs. US$778.43 ± 0.40; p < 0.0001). According to the survey, all surgeons found routine use of FC useful. CONCLUSION In this study, FC was effective in delineating important anatomic structures. It required less time and expense than IOC, and was perceived by the surgeons to be easier to perform, and at least as useful as IOC. Further prospective studies are warranted to evaluate the effectiveness of FC in decreasing BDI.
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Milone L, Coratti A, Daskalaki D, Fernandes E, Giulianotti PC. [Robotic hepatobiliary and gastric surgery]. Chirurg 2013; 84:651-64. [PMID: 23942961 DOI: 10.1007/s00104-013-2581-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Hepatobiliary surgery is a challenging surgical subspecialty that requires highly specialized training and an adequate level of experience in order to be performed safely. As a result, minimally invasive hepatobiliary surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant about the approach. On the other hand, gastric surgery is a very popular field of surgery with an extensive amount of literature especially regarding open and laparoscopic surgery but not much about the robotic approach especially for oncological disease. Recent development of the robotic platform has provided a tool able to overcome many of the limitations of conventional laparoscopic hepatobiliary surgery. Augmented dexterity enabled by the endowristed movements, software filtration of the surgeon's movements, and high-definition three-dimensional vision provided by the stereoscopic camera, allow for steady and careful dissection of the liver hilum structures, as well as prompt and precise endosuturing in cases of intraoperative bleeding. These advantages have fostered many centers to widen the indications for minimally invasive hepatobiliary and gastric surgery, with encouraging initial results. As one of the surgical groups that has performed the largest number of robot-assisted procedures worldwide, we provide a review of the state of the art in minimally invasive robot-assisted hepatobiliary and gastric surgery.The English full-text version of this article is available at SpringerLink (under supplemental).
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Affiliation(s)
- L Milone
- Department of Surgery, Division of Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood MC 958 Room 435 E, 60612, Chicago, IL, USA
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Schols RM, Bouvy ND, van Dam RM, Masclee AAM, Dejong CHC, Stassen LPS. Combined vascular and biliary fluorescence imaging in laparoscopic cholecystectomy. Surg Endosc 2013; 27:4511-7. [PMID: 23877766 DOI: 10.1007/s00464-013-3100-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 06/28/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND Bile duct injury in patients undergoing laparoscopic cholecystectomy is a rare but serious complication. Concomitant vascular injury worsens the outcome of bile duct injury repair. Near-infrared fluorescence imaging using indocyanine green (ICG) is a promising, innovative, and noninvasive method for the intraoperative identification of biliary and vascular anatomy during cholecystectomy. This study assessed the practical application of combined vascular and biliary fluorescence imaging in laparoscopic gallbladder surgery for early biliary tract delineation and arterial anatomy confirmation. METHODS Patients undergoing elective laparoscopic cholecystectomy were enrolled in this prospective, single-institutional study. To delineate the major bile ducts and arteries, a dedicated laparoscope, offering both conventional and fluorescence imaging, was used. ICG (2.5 mg) was administered intravenously immediately after induction of anesthesia and in half of the patients repeated at establishment of critical view of safety for concomitant arterial imaging. During dissection of the base of the gallbladder and the cystic duct, the extrahepatic bile ducts were visualized. Intraoperative recognition of the biliary structures was registered at set time points, as well as visualization of the cystic artery after repeat ICG administration. RESULTS Thirty patients were included. ICG was visible in the liver and bile ducts within 20 minutes after injection and remained up to approximately 2 h, using the ICG-filter of the laparoscope. In most cases, the common bile duct (83%) and cystic duct (97%) could be identified significantly earlier than with conventional camera mode. In 13 of 15 patients (87%), confirmation of the cystic artery was obtained successfully after repeat ICG injection. No per- or postoperative complications occurred as a consequence of ICG use. CONCLUSION Biliary and vascular fluorescence imaging in laparoscopic cholecystectomy is easily applicable in clinical practice, can be helpful for earlier visualization of the biliary tree, and is useful for the confirmation of the arterial anatomy.
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Affiliation(s)
- Rutger M Schols
- Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands,
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Buchs NC, Pugin F, Azagury DE, Jung M, Volonte F, Hagen ME, Morel P. Real-time near-infrared fluorescent cholangiography could shorten operative time during robotic single-site cholecystectomy. Surg Endosc 2013; 27:3897-901. [PMID: 23670747 DOI: 10.1007/s00464-013-3005-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 04/26/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND With the introduction of a new platform, robotic single-site cholecystectomy (RSSC) has been reported as feasible and safe for selected cases. In parallel, the development of real-time near-infrared fluorescent cholangiography using indocyanine green (ICG) has been seen as a help during the dissection, even if the data are still preliminary. The study purpose is to report our experience with ICG RSSC and compare the outcomes to standard RSSC. METHODS From February 2011 to December 2011, 44 selected patients underwent RSSC for symptomatic cholelithiasis. Among them, 23 (52.3%) were included in an experimental protocol using the ICG, and the remainder (47.7%) underwent standard RSSC. There was no randomization. The endpoints were the perioperative outcomes. This is a prospective study, approved by our local Ethics Committee. RESULTS There were no differences in terms of patients' characteristics, except that there were more male patients in the ICG group (47.8 vs. 9.5%; p = 0.008). Regarding the surgical data, the overall operative time was shorter for the ICG group, especially for patients with a body mass index (BMI) ≤25 (-24 min) but without reaching statistical significance (p = 0.06). For BMI >25, no differences were observed. Otherwise, there were no differences in terms of conversion, complications, or length of stay between both groups. CONCLUSIONS A RSSC with a real-time near-infrared fluorescent cholangiography can be performed safely. In addition, for selected patients with a low BMI, ICG could shorten the operative time during RSSC. Larger studies are still required before drawing definitive conclusions.
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Affiliation(s)
- Nicolas C Buchs
- Clinic for Visceral and Transplantation Surgery, Department of Surgery, Faculty of Medicine, University Hospital of Geneva, University of Geneva, Rue Gabriel-Perret-Gentil, 4, 1211, Geneva 14, Switzerland,
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Verbeek FPR, van der Vorst JR, Schaafsma BE, Hutteman M, Bonsing BA, van Leeuwen FWB, Frangioni JV, van de Velde CJH, Swijnenburg RJ, Vahrmeijer AL. Image-guided hepatopancreatobiliary surgery using near-infrared fluorescent light. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 19:626-37. [PMID: 22790312 PMCID: PMC3501168 DOI: 10.1007/s00534-012-0534-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Improved imaging methods and surgical techniques have created a new era in hepatopancreatobiliary (HPB) surgery. Despite these developments, visual inspection, palpation, and intraoperative ultrasound remain the most utilized tools during surgery today. This is problematic, though, especially in laparoscopic HPB surgery, where palpation is not possible. Optical imaging using near-infrared (NIR) fluorescence can be used for the real-time assessment of both anatomy (e.g., sensitive detection and demarcation of tumours and vital structures) and function (e.g., assessment of luminal flow and tissue perfusion) during both open and minimally invasive surgeries. Methods This article reviews the published literature related to preclinical development and clinical applications of NIR fluorescence imaging during HPB surgery. Results NIR fluorescence imaging combines the use of otherwise invisible NIR fluorescent contrast agents and specially designed camera systems, which are capable of detecting these contrast agents during surgery. Unlike visible light, NIR fluorescent light can penetrate several millimetres through blood and living tissue, thus providing improved detectability. Applications of this technique during HPB surgery include tumour imaging in liver and pancreas, and real-time imaging of the biliary tree. Conclusions NIR fluorescence imaging is a promising new technique that may someday improve surgical accuracy and lower complications.
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Affiliation(s)
- Floris P R Verbeek
- Department of Surgery, University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
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Abstract
Although the modern surgical era is highlighted by multiple technological advances and innovations, one area that has remained constant is the dependence of the surgeon's vision on white-light reflectance. This renders different body tissues in a limited palette of various shades of pink and red, thereby limiting the visual contrast available to the operating surgeon. Healthy tissue, anatomic variations, and diseased states are seen as slight discolorations relative to each other and differences are inherently limited in dynamic range. In the upcoming years, surgery will undergo a paradigm shift with the use of targeted fluorescence imaging probes aimed at augmenting the surgical armamentarium by expanding the "visible" spectrum available to surgeons. Such fluorescent "smart probes" will provide real-time, intraoperative, pseudo-color, high-contrast delineation of both normal and pathologic tissues. Fluorescent surgical molecular guidance promises another major leap forward to improve patient safety and clinical outcomes, and to reduce overall healthcare costs. This review provides an overview of current and future surgical applications of fluorescence imaging in diseased and nondiseased tissues and focus on the innovative fields of image processing and instrumentation.
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Affiliation(s)
- Ryan K Orosco
- Division of Head and Neck Surgery, University of California San Diego, La Jolla, CA 92093-0647, USA
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Murawa D, Polom K, Rho YS, Murawa P. Developments in near-infrared-guided hepatobiliary, pancreatic and other upper gastrointestinal surgery. CONTRAST MEDIA & MOLECULAR IMAGING 2013; 8:211-9. [DOI: 10.1002/cmmi.1519] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 10/21/2012] [Accepted: 11/06/2012] [Indexed: 12/29/2022]
Affiliation(s)
- Dawid Murawa
- First Surgical Oncology and General Surgery Department; Greater Poland Cancer Center; Poznan; Poland
| | - Karol Polom
- First Surgical Oncology and General Surgery Department; Greater Poland Cancer Center; Poznan; Poland
| | - Young Soo Rho
- Department of Oncological Pathomorphology; Poznan University of Medical Sciences; Poznan; Poland
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Real-time near-infrared (NIR) fluorescent cholangiography in single-site robotic cholecystectomy (SSRC): a single-institutional prospective study. Surg Endosc 2012; 27:2156-62. [PMID: 23271272 DOI: 10.1007/s00464-012-2733-2] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 12/01/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Bile duct injury is a rare but serious complication of laparoscopic cholecystectomy and the primary cause is misinterpretation of biliary anatomy. This may occur more frequently with a single-incision approach due to difficulties in exposing and visualizing the triangle of Calot. Intraoperative cholangiography was proposed to overcome this problem, but due to multiple issues, it is not used routinely. Indocyanine green (ICG) near-infrared (NIR) fluorescent cholangiography is non invasive and provides real-time biliary images during surgery, which may improve the safety of single-incision cholecystectomy. This study aims to evaluate the efficacy and safety of this technique during single-site robotic cholecystectomy (SSRC). METHODS Patients presenting with symptomatic biliary gallstones without suspicion of common bile duct stones underwent SSRC with ICG-NIR fluorescent cholangiography using the da Vinci Fluorescence Imaging Vision System. During patient preparation, 2.5 mg of ICG was injected intravenously. During surgery, the biliary anatomy was imaged in real time, which guided dissection of Calot's triangle. Perioperative outcomes included biliary tree visualizations, operative time, conversion and complications rates, and length of hospital stay. RESULTS There were 45 cases between July 2011 and January 2012. All procedures were completed successfully; there were no conversions and at least one structure was visualized in each patient. The rates of visualization were 93 % for the cystic duct, 88 % for the common hepatic duct, and 91 % for the common bile duct prior to Calot's dissection; after Calot's dissection, the rates were 97 % for all three ducts. Mean hospital stay was 1.1 days and there were no bile duct injuries or any other major complications. CONCLUSION Real-time high-resolution fluorescent imaging to identify the biliary tree anatomy during SSRC using the da Vinci Fluorescence Imaging Vision System was safe and effective.
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Schols RM, Bouvy ND, van Dam RM, Stassen LPS. Advanced intraoperative imaging methods for laparoscopic anatomy navigation: an overview. Surg Endosc 2012; 27:1851-9. [PMID: 23242493 DOI: 10.1007/s00464-012-2701-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Accepted: 11/01/2012] [Indexed: 01/14/2023]
Abstract
BACKGROUND Safety and efficiency are important topics in minimally invasive surgery. Apart from its advantages, laparoscopic surgery has the following drawbacks: two-dimensional imaging, challenging eye-hand coordination, and absence of tactile feedback. Enhanced imaging with earlier and clearer identification of essential tissue types can partly overcome these disadvantages. Research groups worldwide are investigating new technologies for image-guided surgery purposes. This review article gives an overview of current developments in surgical optical imaging for improved anatomic identification and physiologic tissue characterization during laparoscopic gastrointestinal surgery. METHODS A systematic literature search in the PubMed database was conducted. Eligible studies reported on any kind of novel optical imaging technique applied for anatomic identification or physiologic tissue characterization in laparoscopic gastrointestinal surgery. Gynecologic and urologic procedures also were included whenever vascular, nerve, ureter, or lymph node imaging was concerned. RESULTS Various surgical imaging techniques for enhanced intraoperative visualization of essential tissue types (i.e., blood vessel, bile duct, ureter, nerve, lymph node) and for tissue characterization purposes such as assessment of blood perfusion were identified. An overview of preclinical and clinical experiences is given as well as the potential added value for intraoperative anatomic localization and characterization during laparoscopy. CONCLUSION Implementation of new optical imaging methods during laparoscopic gastrointestinal surgery can improve intraoperative anatomy navigation. This may lead to increased patient safety (preventing iatrogenic functional tissue injury) and procedural efficiency (shorter operating time). Near-infrared fluorescence imaging seems to possess the greatest potential for implementation in clinical practice in the near future.
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Affiliation(s)
- Rutger M Schols
- Department of Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202, AZ Maastricht, The Netherlands.
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