Intracholecystic versus intravenous indocyanine green for visualization of biliary anatomy during laparoscopic cholecystectomy: a randomized controlled study.

Background: Use of Indocyanine green (ICG) dye and near infrared fluorescence has been recently described for visualizing the extrahepatic biliary anatomy during laparoscopic cholecystectomy (LC). The popular route for administration of ICG is intravenous (IV), 30-60 min before surgery. Direct injection of ICG into gall bladder (intracholecystic) (IC) is not commonly used. This study is designed to compare these two routes of ICG for visualization of extrahepatic biliary anatomy.

Methods and procedure: Forty patients undergoing elective LC were included and randomized into two groups of 20 patients each: IV-ICG and IC-ICG. In the IV-ICG group, ICG was administered in a dose of 0.01 mg/kg, 30-45 min before induction of anesthesia. In the IC-ICG group, ICG was injected directly into the gall bladder fundus using an 18-gauge needle. The two groups were compared with respect to the time of appearance of fluorescence in the biliary tree. A 5-point score was designed to compare the visualization of the biliary anatomy in the two groups.

Results: The mean visualization score in the IV-ICG group was 4.25 ± 1.17, while that in the IC-ICG group was 4.1 ± 1.18. The cystic duct could be delineated pre-dissection in 70% patients in IV-ICG and in 85% patients in IC-ICG, which changed to 85% and 95%, respectively, after dissection of Calot's triangle. IV-ICG was found to be better at delineating the common hepatic duct (85%) compared to IC-ICG (45%), while CBD could be seen in 95% and 100% patients, respectively. Two patients in the IC-ICG group had minor leakage of bile from the puncture hole in the fundus.

Conclusions: This study found that the IC-ICG provides a faster visualization of extrahepatic biliary ducts during LC, with a better signal-to-background ratio compared to the IV-ICG. It can be utilized immediately without the need to wait for the dye to be excreted by the liver.