Does ICG Fluorescence Cholangiography Identify Critical View of Safety Earlier in Laparoscopic Cholecystectomy
Does ICG Fluorescence Cholangiography Identify Critical View of Safety Earlier in Laparoscopic Cholecystectomy
Achievement of critical view of safety (CVS) is recommended to reduce risk of hilar injury in
 laparoscopic cholecystectomy. Indocyanine green (ICG) fluorescence cholangiography, a novel
 technique of real time biliary visualization, is postulated to assist dissection during
 laparoscopic cholecystectomy (LC). However, its use in providing a faster and safer LC has
 yet to be established. The main objective of this study is to evaluate whether the use of ICG
 enhanced fluorescence cholangiography will help in earlier identification critical view of
 safety during LC.
Indocyanine green (ICG) is excreted exclusively in the biliary system and emits fluorescence
 light when viewed using near infrared imaging. This enables extrahepatic biliary tree anatomy
 to be delineated during laparoscopic cholecystectomy.

 Indocyanine green fluorescence cholangiography also enables earlier detection of cystic duct
 and common bile duct during laparoscopic cholecystectomy. This is reported in two studies
 which showed that cystic duct can be identified 11 minutes and 8.6 minutes earlier and common
 bile duct 10 and 11 minutes earlier than white light imaging.

 To date, there is no data published on the use of fluorescent cholangiography in reducing
 operative time of identification of critical view of safety during laparoscopic
 cholecystectomy, which is an integral part of the surgery. Theoretically achievement of
 critical view of safety maybe facilitated by fluorescent cholangiography as this technique
 facilitates identification of biliary structures.

 The primary objective of this study is to evaluate whether an earlier identification of CVS
 can be obtained by using ICG fluorescence cholangiography as an adjunct to conventional
 laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy. Secondary
 outcomes assessed are the presence of minor or major complications between this two groups.

 Patients are randomly assigned into two arms; ICG fluorescence cholangiography assisted
 laparoscopic cholecystectomy (ICGFC- LC) and conventional laparoscopic cholecystectomy (LC),
 using a computer-generated block randomization. Patients in the ICGFC- LC group received
 intravenous bolus of 2.5mg of ICG before the induction of anaesthesia. All the surgeries are
 performed using standard four ports technique. Near infrared light camera by Karl Storz
 Endoscopy is used intermittently during dissection for the ICGFC-LC group.

 Time to identification of CVS is defined by time of gallbladder retraction to time of
 establishment of critical view of safety. Critical view of safety is achieved when all the
 three criteria set by Strasberg is met. Mean time to identification of CVS in the two groups
 of patients were then compared. All patients are followed up for one month to identify any
 post-operative complications.
Inclusion Criteria:

 -  Symptomatic cholelithiasis for elective cholecystectomy

 -  American Society of Anaesthesiologist (ASA) classification of physical status I or II

 -  Normal kidney function

 -  Normal liver function

 Exclusion Criteria:

 -  Liver cirrhosis

 -  Hepatits B or C

 -  Allergies to iodine or seafood