Intraoperative Indocyanine Green During Cholecystectomy

  • Fernando Dip
  • Mayank Roy
  • Matthew Roche
  • Armando Rosales
  • Emanuele Lo Menzo
  • Raul J. RosenthalEmail author


The introduction of laparoscopic techniques has revolutionized the approach to cholecystectomy. Among the clear advantages of this approach are the quicker recovery time and overall decreased morbidity. However, concerns still remain on the higher likelihood of extrahepatic bile duct injuries. Among the different reasons to explain the reason for bile duct injury during laparoscopic cholecystectomy, misinterpretation of the visualized structures remains the most common. Several techniques to improve intraoperative identification of the biliary anatomy have been described. Intraoperative cholangiography is currently the most commonly utilized technique. However, this technique has only been shown to aid in the earlier identification of an injury and not in the prevention of it. Endoscopic ultrasound is the other common technique utilized, but this technique requires a significant learning curve and could be misinterpreted. Near-infrared fluorescent cholangiography (NIRFC) has been described as an effective technique to improve visualization of the extrahepatic biliary anatomy. This technique seems to be effective, easy to learn, cheap, and reproducible. In this chapter we describe the details of this technique and the necessary intraoperative steps to take best advantage of it, based on the current available literature and personal experience.


Fluorescent-guided surgery Bile duct injury Laparoscopic cholecystectomy Indocyanine green 


  1. 1.
    Berci G, et al. Laparoscopic cholecystectomy: first, do no harm; second, take care of bile duct stones. Surg Endosc. 2013;27(4):1051–4.CrossRefGoogle Scholar
  2. 2.
    Way LW, et al. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg. 2003;237(4):460–9.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Stiles BM, et al. Fluorescent cholangiography in a mouse model: an innovative method for improved laparoscopic identification of the biliary anatomy. Surg Endosc. 2006;20(8):1291–5.CrossRefGoogle Scholar
  4. 4.
    Figueiredo JL, et al. Intraoperative near-infrared fluorescent cholangiography (NIRFC) in mouse models of bile duct injury: reply. World J Surg. 2011;35(3):694–5.CrossRefGoogle Scholar
  5. 5.
    Ishizawa T, et al. Intraoperative fluorescent cholangiography using indocyanine green: a biliary road map for safe surgery. J Am Coll Surg. 2009;208(1):e1–4.CrossRefGoogle Scholar
  6. 6.
    Ishizawa T, Bandai Y, Kokudo N. Fluorescent cholangiography using indocyanine green for laparoscopic cholecystectomy: an initial experience. Arch Surg. 2009;144(4):381–2.CrossRefGoogle Scholar
  7. 7.
    Buchs NC, et al. Intra-operative fluorescent cholangiography using indocyanin green during robotic single site cholecystectomy. Int J Med Robot. 2012;8(4):436–40.CrossRefGoogle Scholar
  8. 8.
    Buchs NC, et al. Real-time near-infrared fluorescent cholangiography could shorten operative time during robotic single-site cholecystectomy. Surg Endosc. 2013;27(10):3897–901.CrossRefGoogle Scholar
  9. 9.
    Dip F, et al. Routine use of fluorescent incisionless cholangiography as a new imaging modality during laparoscopic cholecystectomy. Surg Endosc. 2015;29(6):1621–6.CrossRefGoogle Scholar
  10. 10.
    Dip F, et al. Accuracy of near infrared-guided surgery in morbidly obese subjects undergoing laparoscopic cholecystectomy. Obes Surg. 2016;26(3):525–30.CrossRefGoogle Scholar
  11. 11.
    Roy M, et al. Fluorescent incisionless cholangiography as a teaching tool for identification of Calot’s triangle. Surg Endosc. 2017;31(6):2483–90.CrossRefGoogle Scholar
  12. 12.
    Pertsemlidis D. Fluorescent indocyanine green for imaging of bile ducts during laparoscopic cholecystectomy. Arch Surg. 2009;144(10):978.CrossRefGoogle Scholar
  13. 13.
    Schols RM, et al. Near-infrared fluorescence laparoscopy of the cystic duct and artery in pigs: performance of a preclinical dye. J Laparoendosc Adv Surg Tech A. 2014;24(5):318–22.CrossRefGoogle Scholar
  14. 14.
    Ishizawa T, et al. Fluorescent cholangiography illuminating the biliary tree during laparoscopic cholecystectomy. Br J Surg. 2010;97(9):1369–77.CrossRefGoogle Scholar
  15. 15.
    Agarwal BB. Patient safety in laparoscopic cholecystectomy. Arch Surg. 2009;144(10):979.. author reply 979CrossRefGoogle Scholar
  16. 16.
    Tsutsui N, et al. Optimal timing of preoperative indocyanine green administration for fluorescent cholangiography during laparoscopic cholecystectomy using the PINPOINT(R) Endoscopic Fluorescence Imaging System. Asian J Endosc Surg. 2018;11(3):199–205.CrossRefGoogle Scholar
  17. 17.
    Scroggie DL, Jones C. Fluorescent imaging of the biliary tract during laparoscopic cholecystectomy. Ann Surg Innov Res. 2014;8:5.CrossRefGoogle Scholar
  18. 18.
    Verbeek FP, et al. Optimization of near-infrared fluorescence cholangiography for open and laparoscopic surgery. Surg Endosc. 2014;28(4):1076–82.CrossRefGoogle Scholar
  19. 19.
    Osayi SN, et al. Near-infrared fluorescent cholangiography facilitates identification of biliary anatomy during laparoscopic cholecystectomy. Surg Endosc. 2015;29(2):368–75.CrossRefGoogle Scholar
  20. 20.
    Daskalaki D, et al. Indocyanine green (ICG) fluorescent cholangiography during robotic cholecystectomy: results of 184 consecutive cases in a single institution. Surg Innov. 2014;21(6):615–21.CrossRefGoogle Scholar
  21. 21.
    Kaneko J, et al. Indocyanine green reinjection technique for use in fluorescent angiography concomitant with cholangiography during laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech. 2012;22(4):341–4.CrossRefGoogle Scholar
  22. 22.
    Kaibori M, et al. Intraoperative indocyanine green fluorescent imaging for prevention of bile leakage after hepatic resection. Surgery. 2011;150(1):91–8.CrossRefGoogle Scholar
  23. 23.
    Dip FD, Asbun D, Rosales-Velderrain A, et al. Cost analysis and effectiveness comparing the routine use of intraoperative fluorescent cholangiography with fluoroscopic cholangiogram in patients undergoing laparoscopic cholecystectomy. Surg Endosc. 2014;28(6):1838–43.CrossRefGoogle Scholar

Copyright information

© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020

Authors and Affiliations

  • Fernando Dip
    • 1
  • Mayank Roy
    • 1
  • Matthew Roche
    • 1
  • Armando Rosales
    • 1
  • Emanuele Lo Menzo
    • 1
  • Raul J. Rosenthal
    • 1
    Email author
  1. 1.Department of SurgeryCleveland Clinic FloridaWestonUSA

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