Abstract
Introduction:
The crucial step in laparoscopic cholecystectomy (LC) is to accurately identify the extrahepatic bile ducts and misidentification tends to cause bile duct injury. 1 However, in complicated cases, this step becomes challenging and difficult. Intraoperative fluorescent cholangiography with indocyanine green (ICG) is a valuable assistance to identify extrahepatic bile ducts during LC. 2 Placement of nasobiliary (NB) drainage tubes is a widely accepted method for drainage of biliary tree following ERCP, which can also be used to administer ICG during LC to reduce the risk of bile duct injury. (BDI) This video demonstrates the utility of this technique in a difficult LC.
Materials and Methods:
A 42-year-old male patient presented with an intermittent right upper abdominal pain, which had persisted for one and a half months. He had normal liver function and inflammation tests on admission. His magnetic resonance cholangiopancreatography revealed a large gallstone impacted in the gallbladder neck, which caused a defect in the common hepatic duct (CHB). Further evaluation with ERCP showed that there was neither narrowing nor fistula in the CHB. These findings simulated Mirizzi syndrome. At the end of ERCP, a NB tube was placed into the biliary tree with its tip in the right hepatic duct. During LC, ICG solution with a concentration of 0.025 mg/mL was injected into the biliary tree through the NB tube. A safe dissection plane was obtained including a critical view of safety. Ultimately, the cystic duct was clipped, and the gallbladder was detached from the liver bed.
Results:
The operative time was 2 hours and there was no major bleeding or bile duct injury. The NB tube was removed on the second postoperative day when the amylase level was normal. The patient recovered uneventfully and was discharged on the fourth postoperative day. He has led a normal life for one and a half months.
Conclusion:
Direct administrating ICG into the biliary tree via NB tubes can clearly display the extrahepatic bile ducts with fluorescence and may reduce the risk of bile duct injury during difficult LC. We utilized this technique in complicated gallstone cases associated with concomitant choledocholithiasis, aberrant extrahepatic bile ducts, and Mirizzi syndrome etc.
Runtime of Video: 5 mins 6 secs.
Funding: The work was supported in part by a grant from Japan China Sasakawa Medical Fellowship to Kaijian Chu.
Disclosure statement: All authors declare there is no commercial associations during the past 3 years that might create a conflict of interest in connection with the video.
Consent: The authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.