This video demonstrate Indocyanine green (ICG) Cholecystectomy by Dr R K Mishra at World Laparoscopy Hospital. Fluorescent cholangiography using intravenous injection of ICG may become the optimal tools to confirm the biliary tract anatomy during LC because it has potential advantages over radiographic cholangiography in that it does not require irradiation or dissection of triangle of Calot. NIR fluorescence-assisted LC has the potential to become a standard surgical procedure. Early visualization of the cystic duct and additional imaging of the CBD may increase safety in LC and might offer an alternative to the intraoperative cholangiogram in patients with an increased risk of CBD injury. In contrast to the ease and efficiency of CD and CBD detection by fluorescent imaging in uncomplicated cases, gallbladder pathology appears to create a much more challenging and complex situation.

Gallbladder surgery, particularly laparoscopic cholecystectomy, is one of the most commonly performed procedures worldwide. While standard laparoscopic techniques have drastically improved patient recovery and outcomes, bile duct injuries remain a serious complication. Indocyanine Green (ICG) fluorescence-guided cholecystectomy is a revolutionary approach designed to enhance visualization, reduce complications, and make gallbladder surgery safer and more precise.

What is Indocyanine Green (ICG)?

Indocyanine Green is a water-soluble, fluorescent dye that has been used in medical imaging for decades, primarily in ophthalmology and cardiology. When administered intravenously, ICG binds to plasma proteins and is excreted exclusively by the liver into the bile. Under near-infrared (NIR) light, it fluoresces, allowing surgeons to visualize structures in real time during surgery.

How ICG Cholecystectomy Works

1. Administration of ICG: Typically, a small dose of ICG is injected intravenously about 30–60 minutes before surgery.

2. Fluorescence Imaging: Specialized laparoscopic cameras equipped with near-infrared technology detect the fluorescence of ICG in the bile ducts.

3. Enhanced Visualization: The cystic duct, common bile duct, and gallbladder can be visualized clearly, even in challenging cases with inflammation or obesity.

4. Safe Dissection: Surgeons can safely identify key anatomical landmarks and avoid injury to the bile ducts.

Advantages of ICG Fluorescence-Guided Cholecystectomy

• Reduced Bile Duct Injury: The enhanced visualization significantly lowers the risk of inadvertent bile duct damage, which is a serious complication in traditional laparoscopic cholecystectomy.

• Real-Time Guidance: Surgeons receive live feedback during dissection, improving precision.

• Minimal Learning Curve: For surgeons already skilled in laparoscopy, integrating ICG imaging is straightforward.

• Improved Outcomes in Difficult Cases: In cases with severe inflammation, adhesions, or altered anatomy, ICG helps identify ducts and reduces operative stress.

• No Ionizing Radiation: Unlike traditional cholangiography, ICG imaging does not require X-rays, making it safer for patients and staff.

Clinical Applications

ICG cholecystectomy is particularly beneficial in:

• Acute cholecystitis

• Obesity or complex anatomy

• Revision surgeries where anatomical landmarks are unclear

• Teaching and training, as visualization of biliary anatomy is enhanced

Limitations

• Availability: Requires specialized near-infrared laparoscopic equipment.

• Timing Sensitivity: The timing of ICG injection is crucial for optimal fluorescence.

• Allergic Reactions: Rare cases of hypersensitivity to ICG have been reported.

Future Perspectives

ICG fluorescence is paving the way for precision surgery. Ongoing research is exploring its role in robotic cholecystectomy, liver surgery, and even oncologic procedures. Combining ICG with advanced imaging and AI-assisted navigation could further enhance surgical safety and outcomes.

Conclusion

Indocyanine Green (ICG) Cholecystectomy represents a significant step forward in minimally invasive gallbladder surgery. By providing real-time visualization of biliary anatomy, it reduces complications, enhances surgical confidence, and improves patient safety. As technology continues to evolve, ICG-guided surgery is poised to become the gold standard in laparoscopic cholecystectomy.