Indocyanine green-guided laparoscopic completion cholecystectomy for stump syndrome: A case report

Abstract

BACKGROUND

Gallbladder remnant disease is an uncommon late complication after subtotal cholecystectomy (SC). Reoperation may be difficult because inflammation and adhesions can obscure the biliary anatomy. This case describes the practical value of indocyanine green (ICG) fluorescence during laparoscopic completion cholecystectomy in a complex reoperative setting.

CASE SUMMARY

A 63-year-old man had previously undergone SC because Calot’s triangle could not be safely dissected. Owing to severe inflammation and unsafe Calot’s triangle anatomy, a reconstituting SC was performed. Two years later, he presented with abdominal pain, dark urine, and mild hyperamylasemia. Computed tomography and magnetic resonance cholangiopancreatography demonstrated microlithiasis within the cystic duct stump, local inflammatory changes, and an anomalous cystic duct, with no stones in the common bile duct. Elective laparoscopic completion cholecystectomy was performed after intravenous ICG administration 45 minutes before surgery. Fluorescence imaging clarified the relationship between the remnant, cystic duct, and common bile duct, allowing safe laparoscopic dissection. Recovery was uneventful, and the patient was discharged on postoperative day 1.

CONCLUSION

ICG fluorescence can be a useful adjunct during laparoscopic completion cholecystectomy in selected patients with gallbladder remnant disease.

Key Words: Indocyanine green; Cholecystectomy; Laparoscopy; Subtotal cholecystectomy; Post-cholecystectomy syndrome; Case report

Core Tip: Subtotal cholecystectomy is a valuable bailout strategy in difficult gallbladder surgery but carries a risk of residual stump-related complications. This case highlights that laparoscopic completion cholecystectomy is feasible and safe, even in reoperative settings. Indocyanine green fluorescence imaging enhances visualization of the biliary anatomy, facilitating safer dissection and achievement of the critical view of safety. Its use may reduce operative risk and should be considered in selected complex cases.

INTRODUCTION

Laparoscopic cholecystectomy has replaced open cholecystectomy as the standard treatment for most benign gallbladder disease since the 1990s owing to its lower surgical trauma and shorter postoperative recovery. Current indications include acute or chronic cholecystitis, symptomatic cholelithiasis, biliary dyskinesia, acalculous cholecystitis, biliary pancreatitis, and selected gallbladder neoplasms.

Gallstone disease affects approximately 20 million people in the United States, and about 300000 cholecystectomies are performed each year. Although 10%-15% of patients remain asymptomatic, nearly 4% develop complications. The prevalence increases with age and is higher among women[1].

Bile duct injury remains one of the most feared complications of cholecystectomy, with reported rates ranging from 0.4% to 1.4%. Achieving the critical view of safety (CVS) is central to reducing this risk; however, dense inflammation or distorted hilar anatomy may render safe dissection impossible. In such cases, subtotal cholecystectomy (SC) is an accepted bailout strategy, although it may leave residual stones or a symptomatic gallbladder remnant.

Two main SC techniques have been described: Reconstituting SC, in which the remnant is closed but retained stones may remain, and fenestrating SC, in which the remnant is left open and is associated with a higher risk of bile leakage but fewer recurrent biliary events.

Post-cholecystectomy syndrome related to the gallbladder remnant may present as stump lithiasis (approximately 4%) or stump cholecystitis (approximately 1.4%). In selected patients, definitive treatment requires completion cholecystectomy[2].

Symptomatic gallbladder remnants have historically been reported more often after open surgery, with rates ranging from 52.4% to 100% in selected series[3].

CASE PRESENTATION

Chief complaints

A 63-year-old man underwent elective laparoscopic cholecystectomy in September 2023 for symptomatic cholelithiasis.

History of present illness

Two years after the index procedure, the patient presented with abdominal pain, dark urine, and mild hyperamylasemia, with a serum amylase level of 180 U/L. In April 2025, abdominal computed tomography was requested for urological assessment of possible renal stones. Incidentally, the scan demonstrated hyperdense material within the cystic stump, consistent with microlithiasis, together with inflammatory thickening of the stump wall suggestive of cystic stump cholecystitis. After surgical assessment, completion cholecystectomy of the gallbladder remnant was planned.

The postoperative course was uneventful, and the patient was discharged on postoperative day 1. No complications were recorded during outpatient follow-up. Histopathological examination confirmed the diagnosis (Figure 1). Informed consent was obtained from the patient before each surgical procedure and for publication of this manuscript.

Figure 1 Gross specimen of the gallbladder remnant cystic duct stump following completion cholecystectomy. The orange circle indicates the metallic clips from the previous subtotal cholecystectomy.

History of past illness

The medical history of the patient included hypertensive heart disease with aortic stenosis, hypercholesterolemia, hyperuricemia, and impaired glucose tolerance.

Personal and family history

The patient had a history of previous surgery.

Physical examination

The patient was obese.

Laboratory examinations

Mild hyperamylasemia was noted, with a serum amylase level of 180 U/L.

Imaging examinations

Preoperative imaging demonstrated residual lithiasis in the cystic duct stump and inflammatory changes consistent with stump cholecystitis. Magnetic resonance cholangiopancreatography confirmed cystic duct anomalies with microlithiasis (Figure 2). The cystic duct inserted caudally and medially into the common bile duct and was ectatic along its cranial portion, measuring 9 mm in diameter and containing millimetric stones. The intrahepatic bile ducts and the common bile duct were not dilated, and no stones were identified along their course.

Figure 2 Preoperative magnetic resonance cholangiopancreatography demonstrating an anomalous cystic duct with microlithiasis. The orange arrow indicates the gallbladder remnant with stones.

FINAL DIAGNOSIS

Residual lithiasis in the cystic duct stump and inflammatory changes consistent with stump cholecystitis.

TREATMENT

In September 2025, the patient underwent laparoscopic completion cholecystectomy with indocyanine green (ICG) fluorescence guidance (Figure 3). According to our institutional protocol, 25 mg of diluted ICG was administered intravenously 45 min before surgery[4].

Figure 3 Laparoscopic completion cholecystectomy with indocyanine green fluorescence guidance. A: Conventional laparoscopic view of Calot’s triangle during reoperation; B: Indocyanine green fluorescence image showing the relationship between the gallbladder remnant and the common bile duct. CBD: Common bile duct.

Near-infrared fluorescence enabled real-time identification of the biliary anatomy and facilitated safe isolation of the cystic duct. Fluorescence cholangiography was performed using the Stryker fluorescence imaging system (Stryker, Portage), including a 10-mm laparoscope, camera head, xenon light-guide cable, video processor/illuminator, and high-definition monitor.

The postoperative course was uneventful, and the patient was discharged on postoperative day 1. No complications were recorded during outpatient follow-up.

OUTCOME AND FOLLOW-UP

Histopathological examination confirmed the diagnosis. One month after surgery, the patient was following an active lifestyle and tolerating a normal diet.

DISCUSSION

Laparoscopic cholecystectomy is the most frequently performed intra-abdominal operation. The CVS is a key step in preventing bile duct injury; however, it cannot always be achieved in the presence of severe inflammation, fibrosis, or distorted biliary anatomy. In such cases, the surgeon must choose among alternative strategies, including bailout SC, conversion to open surgery, or intraoperative cholangiography.

SC provides a pragmatic option when dissection of Calot’s triangle would be unsafe. ICG fluorescence cholangiography can further assist the surgeon by improving visualization of the biliary structures during difficult dissection[2]. Reported intervals between SC and reoperation generally range from 24 to 60 months, and laparoscopic completion cholecystectomy has been shown to be feasible, with a low conversion rate of approximately 1.25%[3]. Preoperative magnetic resonance cholangiopancreatography is highly accurate for identifying remnant gallbladder or cystic duct pathology, with reported accuracy ranging from 92% to 100%[3]. ICG fluorescence has also been associated with faster and safer achievement of the CVS[5]. Nevertheless, the optimal dose and timing of ICG administration remain uncertain. In the present case, a low-dose protocol administered 45 min before surgery provided adequate intraoperative visualization. This adjunct did not replace surgical judgment, which remains essential in reoperative biliary surgery.

Although this is not the first report describing the use of ICG fluorescence during completion cholecystectomy[6], the technique has not yet been incorporated into widely accepted international guidelines as a standard recommendation for this specific indication. Its broader adoption is limited by the difficulty of standardizing emergency and reoperative biliary procedures and by the limited availability of comparable clinical series.

Additional case reports and prospective data on ICG-guided surgery for gallbladder remnants may help define reproducible indications, optimal timing protocols, and safety endpoints. Accumulated evidence could then support expert recommendations for selected complex biliary cases.

CONCLUSION

Laparoscopic completion cholecystectomy with ICG fluorescence guidance appears to be a feasible and safe approach for selected patients with symptomatic gallbladder or cystic duct remnants. In reoperative settings, ICG fluorescence may improve intraoperative orientation and facilitate safer dissection, although it should be considered an adjunct rather than a substitute for surgical expertise. As the literature on ICG-assisted surgery for gallbladder remnants remains limited, further well-documented cases and prospective studies are needed to clarify its role and support future recommendations.