Real-Time Indocyanine Green Fluorescence Navigation in Difficult Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy (LC), with its advantages of minimal invasiveness and rapid recovery, has become the standard surgical approach for benign gallbladder diseases. However, even experienced surgeons cannot completely avoid bile duct injury (BDI), and the incidence of BDI during LC is 2-3 times higher than that of open surgery, making it the most common cause of iatrogenic BDI. Approximately 20% of BDIs require multiple surgeries, and about 0.8% eventually result in liver transplantation, significantly impacting patient safety and quality of life, while posing a major risk for medical disputes. Achieving real-time intraoperative visualization is crucial to preventing BDI, particularly in difficult cholecystectomy cases under inflammatory conditions. Real-time indocyanine green (ICG) fluorescence guidance during LC can enhance extrahepatic bile duct visualization and minimize the risk of bile duct injury. In this surgical protocol, an 83-year-old female patient, who had undergone percutaneous transhepatic gallbladder drainage (PTGBD) for acute suppurative cholecystitis 6 weeks prior, was admitted for LC. During the operation, 2.5 mg of ICG was intravenously administered 10 min before the skin incision. Twenty minutes after injection, the liver and common bile duct were clearly visualized under fluorescence imaging. As the dissection of Calot's triangle progressed, the gallbladder and cystic duct remained unstained due to stone impaction, creating a stark visual contrast. Under dynamic ICG guidance, Calot's triangle was meticulously dissected, and the cystic artery and cystic duct were sequentially ligated and divided. The gallbladder was successfully removed. The surgical field showed no bleeding, and fluorescence imaging confirmed no bile leakage, achieving visualized LC under severe inflammatory adhesions. The patient was discharged on the third postoperative day. Real-time ICG fluorescence navigation for LC is safe, effective, and minimally invasive, particularly suitable for difficult cases.