How can fluorescence imaging support anatomical identification during minimally invasive gallbladder surgery? This educational surgical video from World Laparoscopy Hospital explores three-port laparoscopic cholecystectomy using indocyanine green fluorescence cholangiography, combining a reduced-port operative approach with real-time imaging of the biliary tree.

The technique is relevant to general surgeons, laparoscopic surgery fellows, postgraduate trainees, and healthcare professionals seeking to understand evolving technologies in minimally invasive surgery. Its central focus is the relationship between operative exposure, biliary anatomy, fluorescence imaging, and the principles that guide safe cholecystectomy.

Combining Reduced-Port Surgery with Fluorescence Technology

Laparoscopic cholecystectomy involves removing the gallbladder through small abdominal incisions using a camera and specialized instruments. In a three-port approach, the surgeon works through three access points rather than the conventional four-port configuration. This requires careful planning of instrument positions, traction, and camera movement to maintain an adequate view of the operative field.

ICG fluorescence cholangiography adds another source of anatomical information. After ICG administration, a compatible near-infrared system can display fluorescent bile-containing structures, helping the surgeon interpret the biliary anatomy during selected stages of the procedure.

The goal is not simply to use fewer ports or newer technology. The priority remains an accurate understanding of anatomy and a safe operative strategy tailored to the patient.

How ICG Fluorescence Supports Biliary Identification

The cystic duct connects the gallbladder to the main biliary pathway. Because the bile ducts can have anatomical variations, incorrect identification during cholecystectomy can lead to serious injury.

ICG fluorescence imaging may help visualize the cystic duct and extrahepatic biliary tree without requiring X-ray-based imaging for that fluorescence view. European Association for Endoscopic Surgery consensus recommendations support the use of fluorescence imaging to improve visualization of biliary structures when the technology is available. However, the strength of evidence for improvements in clinical outcomes varies, and fluorescence imaging has recognized technical limitations.

Major Steps in the Operative Approach

Preoperative planning and patient assessment

The surgeon reviews the patient's symptoms, imaging, medical history, and the indication for gallbladder removal. The team determines whether a three-port approach is appropriate and considers whether ICG imaging could provide useful additional information.

Port placement and camera orientation

The laparoscope and working instruments are introduced through carefully selected ports. Suitable positioning allows the surgeon to expose the gallbladder and manipulate tissue while maintaining a clear view of the operative field.

Exposure of the hepatocystic triangle

The surgeon applies controlled traction to expose the relevant anatomy. Adhesions and inflammatory changes may make this step more challenging. Careful dissection and ongoing reassessment are important when the normal anatomical planes are difficult to recognize.

ICG fluorescence assessment

The near-infrared imaging mode is used to assess fluorescent biliary structures. Imaging can be checked before dissection and at subsequent stages when anatomical clarification is needed. The fluorescence view is interpreted alongside the conventional laparoscopic image and the operative findings.

Confirmation of safe anatomy

The surgeon works to establish the critical view of safety before dividing the cystic duct and cystic artery. Fluorescence may provide additional orientation, but it cannot replace the required anatomical criteria. If the anatomy remains uncertain, the surgeon should not proceed with division based on fluorescence alone. Additional imaging or a bailout procedure may be necessary to avoid unsafe dissection.

Gallbladder dissection and removal

Following adequate anatomical assessment, the cystic structures are divided using the chosen technique. The gallbladder is dissected from the liver bed, with attention to hemostasis and avoidance of injury to surrounding structures. The specimen is removed through an appropriate port.

Final checks and recovery

The surgeon inspects the operative field and addresses any concerns before completing the procedure. Postoperative care focuses on pain control, recovery from anesthesia, monitoring for complications, and providing appropriate discharge instructions.

Does ICG Make Cholecystectomy Faster and Safer?

ICG fluorescence may improve visualization of biliary anatomy and can assist operative decision-making. Some studies report improvements in operative efficiency, but results are not uniform, and evidence that fluorescence alone reduces bile duct injury remains limited.

The Society of American Gastrointestinal and Endoscopic Surgeons' guideline on intraoperative biliary imaging has issued conditional recommendations favoring conventional intraoperative cholangiography over fluorescence imaging with ICG for certain benign biliary disease scenarios, reflecting the limitations of current comparative evidence. Fluorescence imaging should therefore be considered a useful adjunct, not a universal replacement for other imaging methods.

Likewise, using three ports does not inherently guarantee a shorter operation or fewer complications. The approach must be selected according to the patient's anatomy, disease severity, and the surgeon's expertise.

Educational Significance for Modern Surgeons

This video provides an opportunity to study the integration of reduced-port laparoscopic technique with fluorescence-guided biliary visualization. For trainees, it reinforces several core lessons: plan port placement carefully, maintain effective exposure, interpret imaging critically, establish the critical view of safety, and change the operative strategy when the anatomy is unclear.

Surgical technology is most valuable when combined with sound judgment, technical competence, and a consistent commitment to patient safety.

Watch the complete demonstration from World Laparoscopy Hospital to explore the principles of ICG-guided three-port laparoscopic cholecystectomy and learn how fluorescence imaging can contribute to anatomical assessment during minimally invasive gallbladder surgery.