This video demonstrate Laparoscopic Cholecystectomy with Real-time Near-Infrared Fluorescent Cholangiography by Dr R K Mishra at World Laparoscopy Hospital. Indocyanine green (icg) fluorescent cholangiography also called Fluorescent cholangiography can be considered as a useful tool for intra-operative visualization of the biliary tree during laparoscopic cholecystectomies. Bile duct injury remains the most feared complication of laparoscopic cholecystectomy. Intraoperative cholangiography (IOC) is the current gold standard for biliary imaging and may reduce injury, but is not widely used. Near Infrared Fluorescence Cholangiography (NIRF-C) is a novel non-invasive method for real-time, radiation free, intra-operative biliary mapping. NIRF-C is a safe and effective alternative to IOC for imaging extrahepatic biliary structures during laparoscopic cholecystectomy. Significantly less time was required to perform NIRF-C than IOC and it is significantly cheaper to use compared to IOC. NIRF-C has the potential to decrease bile duct injury at a significantly lower cost than the use of routine IOC during laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has become the gold standard for treating gallbladder diseases, including gallstones and cholecystitis, due to its minimally invasive nature, reduced postoperative pain, and faster recovery. Despite its widespread adoption, one of the significant challenges in laparoscopic cholecystectomy is the accurate identification of biliary anatomy to prevent bile duct injuries, which can lead to serious complications.

Recent advances in imaging technology have introduced real-time near-infrared fluorescent cholangiography (NIRF-C), a breakthrough technique that enhances intraoperative visualization of the biliary tree and improves surgical safety.

What is Near-Infrared Fluorescent Cholangiography?

Near-infrared fluorescent cholangiography uses a fluorescent dye, most commonly indocyanine green (ICG), which binds to bile and emits fluorescence when exposed to near-infrared light. During surgery, a special laparoscope equipped with a near-infrared camera allows the surgeon to visualize the biliary structures in real-time. This enables clear identification of the cystic duct, common bile duct (CBD), and gallbladder anatomy, even in cases with inflammation or anatomical variations.

Advantages of NIRF-C in Laparoscopic Cholecystectomy

1. Enhanced Safety: By providing real-time visualization of the biliary tree, NIRF-C significantly reduces the risk of bile duct injury—a serious complication of laparoscopic cholecystectomy.

2. Minimally Invasive: Unlike traditional intraoperative cholangiography, NIRF-C does not require cannulation or radiation exposure, making the procedure simpler and safer for the patient.

3. Faster Identification of Anatomy: Surgeons can quickly and accurately identify critical structures, reducing operative time and stress during complex dissections.

4. Improved Outcomes in Difficult Cases: NIRF-C is particularly beneficial in cases with acute inflammation, obesity, or aberrant anatomy where visualization is challenging.

5. Reduced Postoperative Complications: By avoiding accidental injuries and ensuring precise dissection, patients experience fewer complications, less postoperative pain, and faster recovery.

How the Procedure Works

1. Preoperative Preparation: ICG is administered intravenously, usually 30–60 minutes before surgery.

2. Standard Laparoscopic Setup: The surgeon establishes pneumoperitoneum and inserts standard laparoscopic ports.

3. Near-Infrared Imaging Activation: Once the laparoscope is introduced, the NIRF camera is activated to visualize fluorescent biliary structures.

4. Safe Dissection: The surgeon carefully dissects Calot’s triangle while continuously observing the fluorescent anatomy to avoid injury.

5. Gallbladder Removal: After confirming the cystic duct and artery, the gallbladder is safely removed using standard laparoscopic techniques.

Clinical Evidence

Multiple studies have demonstrated that NIRF-C improves anatomical visualization, reduces operative time in complex cases, and lowers the incidence of bile duct injuries. Surgeons report higher confidence during dissection, particularly in inflamed or scarred tissue, making it an invaluable tool in modern laparoscopic surgery.

Conclusion

Laparoscopic cholecystectomy with real-time near-infrared fluorescent cholangiography represents a significant leap forward in minimally invasive surgery. By combining advanced imaging with standard laparoscopic techniques, surgeons can perform safer, faster, and more effective gallbladder surgeries. As technology continues to evolve, NIRF-C is likely to become an essential standard in laparoscopic cholecystectomy, offering better patient outcomes and setting a new benchmark in surgical precision.