Laparoscopic cholecystectomy with synchronous navigation of ICG fluorescence and Yellow Enhance mode

Laparoscopic cholecystectomy (LC), widely performed for gallbladder (GB) diseases poses risks of severe complications. To minimize these risks, Tokyo Guidelines 2018 advocated for “safe steps in LC for acute cholecystitis (AC)” including “maintaining the plane of dissection on the GB surface throughout LC”. Moreover, the dissection along the inner layer of the subserosa (SS-inner) of GB helps surgeons avoid bile duct or vascular injury. This step occasionally becomes challenging when distinguishing the GB surface from adjacent fat. ICG, injected into biliary tract, illuminates in green under Infra-red (IR) mode and facilitates the identification of biliary tract. Otherwise, Yellow Enhance (YE) mode developed by Olympus Corporation, which highlights yellow-colored tissues by converting orange-yellow tissues to a clearer yellow, improves the contrast between anatomical structures. In a case of AC following percutaneous transhepatic gallbladder drainage (PTGBD), we applied both ICG fluorescence and YE mode. The ICG injected from PTGBD illuminated the GB surface in green, while YE mode highlighted the fatty tissue in a clearer yellow, facilitating the distinction between these two tissues and the accurate dissection along the SS-inner. An additional advantage of injecting ICG from PTGBD, or from the cannulation tube intraoperatively inserted to GB, over intravenous administration is that the GB surface can be illuminated in cases of GB stone incarceration. The combination of ICG fluorescence and YE mode encourages surgeons to identify the boundary between the GB surface and the surrounding fatty tissues, which assists the accurate dissection along the SS-inner.