Indocyanine Green Fluorescent Cholangiography During Laparoscopic Cholecystectomy and Bile Duct Injury

Importance: Common bile duct (CBD) injury is a rare but devastating complication of laparoscopic cholecystectomy. Intraoperative indocyanine green (ICG) fluorescence cholangiography may improve biliary visualization, but its effect on CBD injury has not been well demonstrated. Objective: To evaluate the association between intraoperative ICG use and CBD injury after laparoscopic cholecystectomy. Design, Setting, and Participants: This cohort study included data from multiple hospitals in the Epic Cosmos dataset for adult patients (18 years and older) undergoing laparoscopic cholecystectomy between 2016 and 2024. Robotic cases, surgery for hepatobiliary malignancies, planned open procedures, and patients with inadequate follow-up were excluded from analysis. Data were analyzed from November 2025 to January 2026. Inverse probability of treatment weighting (IPTW) was used to adjust for confounding by indication. Exposure: Intraoperative ICG fluorescence cholangiography. Main Outcomes and Measures: The primary outcome was CBD injury within 1 year of surgery. Secondary outcomes included subsequent biliary intervention within 1 year, conversion to open surgery, and rates of any nonbiliary postoperative complications within 30 days. Results: A total of 1 266 024 patients were included for analysis, of whom 164 695 (13%) underwent indocyanine green cholangiography. Among them, 118 626 (72.0) were female and 46 069 (28.0) were male; the mean (SD) age was 51 (17) years. ICG use increased from 1143 patients (1.6%) in 2016 to 47 816 (26%) in 2024. After IPTW adjustment, ICG was associated with lower rates of CBD injury (408 [0.25%] vs 659 [0.40%]; relative risk [RR], 0.62; 95% CI, 0.49-0.79; P < .001), need for any subsequent biliary intervention (7387 [4.49%] vs 8902 [5.39%]; RR, 0.83; 95% CI, 0.77-0.90; P < .001), conversion to open surgery (657 [0.40%] vs 1386 [0.84%]; RR, 0.48, 95% CI, 0.40-0.56; P < .001), and nonbiliary complications at 30 days (11 939 [7.25%] vs 14 275 [8.64%]; RR, 0.84; 95% CI, 0.78-0.91; P < .001). Conclusions and Relevance: In this large national cohort, intraoperative ICG use was associated with lower rates of CBD injury, fewer postoperative biliary procedures and nonbiliary complications, and reduced conversion to open surgery. These findings support the use of ICG to enhance biliary safety in laparoscopic cholecystectomy and demonstrate its utility in reducing CBD injury.