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ICG fluorescent cholangiography in difficult laparoscopic cholecystectomy with inflammatory biliary fusion post-cholecystitis and pancreatitis

Epublication WebSurg.com, Feb 2019;19(02). URL: http://websurg.com/doi/vd01en5545

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  • 2019-02-19
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Laparoscopic cholecystectomy in the presence of inflammatory billiary fusion is a technically challenging procedure associated with a 0.5% risk of injury to major extrahepatic bile ducts. Preoperative planning and intraoperative visualization of the anatomy of the biliary tree using an intraoperative cholangiogram reduces the risk or the severity of injury to major biliary ducts. Indocyanine green cholangiography has emerged as a promising non-invasive modality for visualization of extra-hepatic biliary ducts, having the advantage of very easy use repetitively at various stages of critical areas of dissection. This video demonstrates a laparoscopic cholecystectomy in a patient who had an emergency admission for mild acute cholecystitis (as per Tokyo guidelines, 2018) and concomitant moderately severe acute gallstone pancreatitis (revised Atlanta classification) with a preoperative MRCP predictive of biliary inflammatory fusion between the gallbladder neck and the common hepatic duct. Consequently, we planned and performed a laparoscopic cholecystectomy with an indocyanine green cholangiogram as a non-invasive method to help identify the intraoperative anatomy of the extra-hepatic biliary ducts. The main feature of our video is the use of indocyanine green during the difficult dissection of the gallbladder neck and exposure of the critical view of safety in Calot’s triangle as cased with clear features of significant biliary inflammatory fusion between the cystic duct and the common hepatic duct. ICG fluorescent demonstration of the extra-hepatic biliary tree is used in real time and with ease repeatedly at several stages of this difficult dissection, facilitating a safe completion of a difficult laparoscopic cholecystectomy and may become a standard practice.