Role of indocyanine green fluorescence cholangiography in laparoscopic cholecystectomy for complicated gall bladder disease: A prospective comparative study

Abstract Background: Bile duct injury during laparoscopic cholecystectomy (LC) remains an uncommon but serious complication, especially in the presence of inflammation and distorted biliary anatomy. Reported injury rates range from 0.26% to 0.7%, with conversion-to-open rates of 2.6%–10% when the critical view of safety (CVS) cannot be achieved. Indocyanine green fluorescence (ICG-F) imaging has been introduced to improve real-time biliary visualization. This study evaluates its role in complicated gallbladder disease. Methods: This prospective comparative study included 80 patients undergoing LC between May 2024 and October 2025. Patients were divided into ICG-assisted LC ( n = 40) and conventional LC ( n = 40). Difficulty was assessed using Nassar and Sugrue grading systems. Primary outcomes were time to biliary identification and total operative duration. Secondary outcomes included conversion rate, complications, hospital stay, and surgeon satisfaction. Results: Baseline characteristics were comparable ( P > 0.05). The ICG group had significantly shorter time to CVS identification (19.6 ± 5.36 vs. 35.5 ± 5.10 minutes) and total operative time (49.1 ± 11.20 vs. 80.2 ± 9.79 minutes; P < 0.05). Conversion occurred in four conventional cases and none in the ICG group ( P = 0.220). Surgeon satisfaction was higher with ICG ( P < 0.001). Hospital stay was shorter but not significant. Conclusion: ICG-F cholangiography facilitates earlier biliary identification and reduces operative time in difficult LC. Larger multicentre randomized studies are required to confirm its impact on conversion rates and clinical outcomes.