Laparoscopic cholecystectomy (LC) is widely regarded as the gold standard for the surgical management of gallbladder diseases, particularly symptomatic cholelithiasis and chronic cholecystitis. Since its introduction, LC has revolutionized biliary surgery by offering patients reduced postoperative pain, shorter hospital stays, quicker recovery, and minimal scarring compared to open procedures. However, despite advances in technique and instrumentation, bile duct injury (BDI) remains a significant concern. Bile duct injuries, though rare, can lead to severe complications, including bile leakage, strictures, sepsis, and the need for complex reconstructive surgeries. To mitigate these risks, accurate identification of biliary anatomy during surgery is essential. One of the most promising innovations in this context is real-time near-infrared (NIR) fluorescent cholangiography.

Principle of Near-infrared Fluorescent Cholangiography

Near-infrared fluorescent cholangiography (NIRFC) involves the use of a fluorescent dye, typically indocyanine green (ICG), which is administered intravenously prior to or during surgery. ICG is rapidly taken up by the liver and excreted into the bile. When illuminated with near-infrared light, ICG emits fluorescence, allowing surgeons to visualize the biliary anatomy in real-time using specialized NIR-compatible laparoscopic cameras. This technique provides dynamic, real-time imaging of the cystic duct, common bile duct (CBD), and gallbladder, enhancing the surgeon's ability to identify structures accurately without the need for intraoperative X-ray imaging.

Procedure Overview

The procedure begins similarly to a standard laparoscopic cholecystectomy. The patient is placed under general anesthesia, and pneumoperitoneum is established using carbon dioxide insufflation. Trocars are inserted, and the laparoscope is introduced. The operating surgeon dissects the Calot’s triangle carefully to identify the cystic duct and cystic artery. At this stage, the NIRFC system is activated. Depending on institutional protocols, ICG is administered either 30–60 minutes before surgery or intraoperatively. Within minutes, the bile ducts fluoresce under NIR light, allowing the surgeon to distinguish the cystic duct from the CBD and hepatic ducts clearly.

Advantages of Real-time NIR Cholangiography

One of the most significant advantages of NIRFC is the reduction in the risk of bile duct injury. Traditional methods of visualizing biliary anatomy, such as intraoperative cholangiography using X-ray contrast, require cannulation of the cystic duct and expose the patient and staff to ionizing radiation. NIRFC, on the other hand, is non-invasive, radiation-free, and does not require duct cannulation, making it safer and simpler. Real-time imaging allows the surgeon to continuously monitor biliary structures during dissection, clip placement, and gallbladder removal. This dynamic guidance is particularly valuable in cases of acute cholecystitis, fibrosis, or distorted anatomy, where standard anatomical landmarks may be obscured.

In addition to improving safety, NIRFC can reduce operative time by avoiding repeated fluoroscopy checks and facilitating more precise dissection. Studies have shown that the use of fluorescent cholangiography significantly enhances the identification of the cystic duct and CBD, improving surgical confidence and reducing the incidence of complications. Moreover, the learning curve for laparoscopic surgeons is shortened, as even less-experienced surgeons can achieve high rates of safe biliary identification.

Clinical Evidence and Applications

Multiple clinical studies have demonstrated the efficacy of NIRFC in laparoscopic cholecystectomy. Fluorescence imaging has been shown to improve visualization of biliary anatomy in over 90% of cases, even in challenging scenarios such as obese patients or those with severe inflammation. NIRFC is also valuable in detecting anatomical variations, such as aberrant ducts, which may be missed using conventional methods. Its application is not limited to elective cholecystectomy; it is increasingly used in complex hepatobiliary surgeries and in the management of bile duct stones.

Limitations and Considerations

While NIRFC represents a significant advancement, it has limitations. Fluorescence may be obscured in patients with severe liver dysfunction or obstructed bile flow, as ICG excretion into bile may be delayed. Additionally, specialized laparoscopic cameras and NIR systems are required, which can increase the cost of surgery. Despite these limitations, the overall benefits in terms of safety, precision, and reduced risk of complications make NIRFC an increasingly standard adjunct in modern laparoscopic cholecystectomy.

Conclusion

Laparoscopic cholecystectomy with real-time near-infrared fluorescent cholangiography is a transformative advancement in biliary surgery. By enabling precise, dynamic visualization of the biliary anatomy without radiation or invasive catheterization, it significantly enhances surgical safety, reduces the risk of bile duct injuries, and improves overall outcomes. As technology continues to evolve and become more accessible, NIRFC is poised to become an integral component of safe laparoscopic cholecystectomy, setting a new benchmark for precision and patient safety in hepatobiliary surgery.