Fluorescent cholangiography: An up-to-date overview twelve years after the first clinical application

Abstract

Laparoscopic cholecystectomy (LC) is one of the most frequently performed gastrointestinal surgeries worldwide. Bile duct injury (BDI) represents the most serious complication of LC, with an incidence of 0.3%-0.7%, resulting in significant perioperative morbidity and mortality, impaired quality of life, and high rates of subsequent medico-legal litigation. In most cases, the primary cause of BDI is the misinterpretation of biliary anatomy, leading to unexpected biliary lesions. Near-infrared fluorescent cholangiography is widely spreading in clinical practice to delineate biliary anatomy during LC in elective and emergency settings. The primary aim of this article was to perform an up-to-date overview of the evolution of this method 12 years after the first clinical application in 2009 and to highlight all advantages and current limitations according to the available scientific evidence.

Keywords: Laparoscopic cholecystectomy; Bile duct injury; Biliary anatomy; Fluorescent cholangiography; Indocyanine green

Core Tip: Fluorescence image-guided surgery is one of the most recent innovations in laparoscopic and robotic surgery. The visualization of biliary anatomy using fluorescence during surgery is becoming one of the most promising frontier approaches in minimally invasive surgery. This novel method is a powerful tool to detect biliary variants that could guide surgeons during dissection to prevent major bile duct lesions, and it has enormous potential to be considered the gold standard during all cholecystectomies. The up-to-date overview of this method confirms the efficacy of indocyanine green fluorescence cholangiography in detecting biliary anatomy, its importance as a teaching tool for young surgeons, and the effects on the reduction of conversion rate and bile duct injury, even if further considerable research remains necessary to optimize its use.