Laparoscopic cholecystectomy has become the gold standard surgical procedure for the management of symptomatic gallstone disease and other benign gallbladder conditions. “Since its introduction in the late twentieth century, this minimally invasive technique has largely replaced open cholecystectomy due to its advantages of reduced postoperative pain, shorter hospital stay, faster recovery, and improved cosmetic outcomes (1). Despite these benefits, laparoscopic cholecystectomy carries a small but significant risk of bile duct injury, which remains one of the most serious complications associated with the procedure. Bile duct injury can lead to severe morbidity, prolonged hospitalization, repeated interventions, and occasionally life-threatening consequences. Therefore, accurate identification of biliary anatomy during surgery is essential to minimize the risk of such complications (2,3).

One of the primary challenges during laparoscopic cholecystectomy is the proper identification of structures within the hepatocystic triangle, particularly the cystic duct and the common bile duct. Inflammatory conditions such as acute or chronic cholecystitis, fibrosis, adhesions, or anatomical variations can obscure these structures and make dissection difficult (4). Traditionally, surgeons rely on careful dissection and the achievement of the “critical view of safety” to ensure correct identification of biliary structures. In some cases, intraoperative cholangiography using radiographic contrast has been employed to delineate the biliary tree. However, conventional cholangiography requires additional instrumentation, exposure to radiation, and increased operative time, which may limit its routine use (5,6).

In recent years, fluorescence imaging using indocyanine green (ICG) has emerged as a promising technique for intraoperative visualization of biliary anatomy. Indocyanine green is a water-soluble fluorescent dye that binds to plasma proteins following intravenous administration and is rapidly taken up by hepatocytes before being excreted into bile (7). When exposed to near-infrared light, ICG emits fluorescence that can be detected by specialized imaging systems integrated into modern laparoscopic equipment. This property enables real-time visualization of the biliary tree without the need for ionizing radiation or contrast injection into the bile ducts (8,9).

The use of ICG fluorescence cholangiography during laparoscopic cholecystectomy allows surgeons to identify important biliary structures such as the cystic duct, common bile duct, and common hepatic duct before or during dissection of the hepatocystic triangle. By providing enhanced anatomical visualization, this technique may help reduce the risk of bile duct injury and improve surgical safety (10). Furthermore, ICG imaging is relatively simple to perform, does not require cannulation of the cystic duct, and can be repeated multiple times during the operation. These advantages make it an attractive adjunct for minimally invasive hepatobiliary surgery (11).

Several studies have reported that fluorescence cholangiography using ICG improves the identification of biliary structures and assists surgeons in performing safer laparoscopic cholecystectomy, particularly in cases with severe inflammation or distorted anatomy (12). However, factors such as the timing of dye administration, dosage of ICG, and patient-related variables may influence the quality of fluorescence imaging. Therefore, further evaluation of this technique is necessary to determine its clinical usefulness and practical applicability in routine surgical practice (13).

The present study aims to evaluate the use of indocyanine green fluorescence imaging in laparoscopic cholecystectomy and assess its role in improving intraoperative visualization of biliary anatomy and enhancing the safety of the procedure”.

AIMS AND OBJECTIVES

Aim: To evaluate the use of indocyanine green (ICG) fluorescence imaging in laparoscopic cholecystectomy for improved intraoperative visualization of biliary anatomy.

Objective: To assess the effectiveness of indocyanine green fluorescence cholangiography in identifying biliary structures such as the cystic duct and common bile duct during laparoscopic cholecystectomy.

Study design: This study was conducted as a retrospective observational study to evaluate the usefulness of indocyanine green (ICG) fluorescence cholangiography during laparoscopic cholecystectomy. Study setting and duration: “The study was carried out in the Department of General Surgery at a tertiary care hospital over a period of 1 YEAR. Sample size: A total of 65 patients undergoing laparoscopic cholecystectomy were included in the study. Inclusion criteria: Patients were included if they: • Were aged more than 18 years • Had symptomatic gallstone disease or gallbladder pathology requiring laparoscopic cholecystectomy • Provided informed consent for the procedure Exclusion criteria: Patients were excluded if they: • Had known allergy to indocyanine green or iodine • Were pregnant • Had severe hepatic dysfunction • Required primary open cholecystectomy ICG administration: Indocyanine green was administered intravenously at a dose of 2.5 mg approximately 2 hours before surgery to allow excretion of the dye into the biliary system and enable fluorescence imaging during the procedure. Surgical procedure: All patients underwent standard laparoscopic cholecystectomy under general anesthesia using the four-port technique. Near-infrared fluorescence imaging was used intraoperatively to visualize the biliary anatomy after administration of ICG. Visualization of the cystic duct and common bile duct was assessed before or during dissection of Calot’s triangle. The critical view of safety was obtained before clipping and dividing the cystic duct and artery, followed by removal of the gallbladder. Outcome measures: The primary outcome measured was the ability of ICG fluorescence imaging to identify biliary structures such as the cystic duct and common bile duct. Secondary parameters included operative time, intraoperative difficulty, conversion to open surgery, and postoperative complications. Statistical analysis: Data were analyzed using appropriate statistical methods”. Continuous variables were expressed as mean ± standard deviation, and categorical variables were expressed as percentages. A p-value of less than 0.05 was considered statistically significant.

Table 1: Demographic characteristics of patients

Graph 1: Sex Distribution of Patients

The study included 65 patients undergoing laparoscopic cholecystectomy with ICG fluorescence imaging. ^“The mean age was 61.3 years with a slight female predominance.

Table 2: Indications for surgery

Graph 2: Indications for surgery

The majority of patients underwent surgery for symptomatic gallstone disease.

Table 3: Presence of acute cholecystitis

Graph 3: Presence of acute cholecystitis

Almost half of the patients presented with acute cholecystitis, indicating a significant proportion of difficult surgical cases.

Table 4: Visualization of cystic duct using ICG

Graph 4: Visualization of cystic duct using ICG

ICG fluorescence imaging successfully visualized the cystic duct in most patients, demonstrating its usefulness for identifying biliary anatomy during surgery.

Table 5: Visualization of common bile duct using ICG

Graph 5: Visualization of common bile duct using ICG

ICG fluorescence provided excellent visualization of the common bile duct in the majority of cases.

Table 6: Comparison of inflammatory markers with cystic duct visualization

Graph 6: Comparison of WBC with Cystic Duct Visualization

Graph 7: Comparison of CRP with Cystic Duct Visualization

Higher inflammatory markers were significantly associated with failure to visualize the cystic duct using ICG fluorescence imaging.

Table 7: Operative parameters

Graph 8: Operative parameters

The average operative duration was around 133 minutes with minimal blood loss and acceptable hospital stay.

Table 8: Conversion to open surgery

Graph 9: Conversion to open surgery

A small proportion of cases required conversion to open surgery due to severe inflammation or difficulty in identifying anatomy.

Table 9: Association between acute cholecystitis and CD visualization

Graph 10: Association between acute cholecystitis and CD visualization

Patients with acute cholecystitis had significantly lower rates of cystic duct visualization.

Table 10: Postoperative complications

Graph 11: Postoperative complications

The procedure was safe with very low complication rates.

The present study demonstrated that indocyanine green fluorescence cholangiography is an effective tool for intraoperative visualization of biliary anatomy during laparoscopic cholecystectomy. The cystic duct and common bile duct were successfully identified in most patients using near-infrared fluorescence imaging.

Visualization was significantly affected by inflammatory conditions such as acute cholecystitis, which were associated with higher white blood cell counts and CRP levels. Despite this limitation, the use of ICG facilitated safer dissection of Calot’s triangle and helped surgeons achieve the critical view of safety in the majority of cases^”.

The technique was associated with acceptable operative times, low conversion rates, and minimal postoperative complications, indicating that ICG fluorescence imaging is a useful adjunct that can enhance surgical safety and anatomical identification during laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has become the standard treatment for gallbladder disease due to its safety, minimal invasiveness, and faster postoperative recovery. “The present study evaluated the clinical outcomes and surgical safety in patients undergoing laparoscopic cholecystectomy, with particular emphasis on operative findings, complications, and postoperative recovery. Previous literature has consistently emphasized the importance of safe surgical technique and adequate visualization of biliary anatomy to prevent complications.

Asad et al. (2025) described laparoscopic cholecystectomy as the gold standard procedure for symptomatic gallbladder disease, highlighting advantages such as reduced postoperative pain, shorter hospital stay, and early return to normal activity (1). The findings of the present study are consistent with these observations, as the majority of patients experienced uneventful postoperative recovery and were discharged in stable condition following surgery.

One of the most serious complications associated with laparoscopic cholecystectomy is bile duct injury. Renz et al. (2017) emphasized that bile duct injuries can significantly increase postoperative morbidity and often require complex reconstructive surgery (2). Similarly, Machado (2011) reported that most bile duct injuries occur due to misidentification of biliary anatomy during dissection of Calot’s triangle (3). In the present study, careful surgical technique and identification of anatomical landmarks contributed to the low complication rate observed, which aligns with the preventive strategies described in these studies.

The importance of adopting a standardized safety approach during laparoscopic cholecystectomy has been emphasized by Gupta and Jain (2019), who advocated the universal adoption of the “culture of safety in cholecystectomy.” Their study highlighted the importance of achieving the critical view of safety before clipping or dividing the cystic duct and artery (4). The favorable surgical outcomes observed in the present study support this concept, suggesting that adherence to standardized operative principles plays a significant role in reducing complications.

In recent years, fluorescence imaging using indocyanine green (ICG) has been increasingly explored as an adjunct for intraoperative visualization of biliary anatomy. De Simone et al. (2025) reported that ICG fluorescence imaging improves visualization of biliary structures in emergency surgery and may help reduce the risk of bile duct injury (5). Similarly, Symeonidis et al. (2026) conducted a randomized trial comparing standard cholangiography with ICG fluorescence cholangiography and demonstrated improved anatomical identification during laparoscopic cholecystectomy (6). These findings highlight the potential benefits of fluorescence imaging techniques in enhancing surgical safety.

Ravikumar et al. (2025) further demonstrated that the use of ICG fluorescence cholangiography can reduce operative time and improve intraoperative decision-making during laparoscopic cholecystectomy (7). Comparable findings were also reported by Majlesara et al. (2017) and Lim et al. (2023), who described ICG fluorescence imaging as an important advancement in hepatobiliary surgery, providing real-time visualization of biliary anatomy and improving surgical precision (9,11).

The application of near-infrared fluorescence imaging has also been evaluated in complex hepatobiliary procedures. Yu et al. (2021) and Zhou et al. (2024) reported that ICG fluorescence imaging is useful for identifying biliary structures and improving surgical outcomes in hepatobiliary surgery (8,13). Similarly, Losurdo et al. (2023) demonstrated the feasibility of ICG fluorescence cholangiography in urgent and emergency laparoscopic cholecystectomy, suggesting that the technique may enhance surgical safety in difficult cases (12).

The use of ICG fluorescence imaging has also been explored in pediatric surgical settings. Esposito et al. (2021) reported encouraging results with ICG fluorescence cholangiography in pediatric laparoscopic cholecystectomy, highlighting improved visualization of biliary anatomy and reduced risk of iatrogenic injury (10). These findings further support the expanding role of fluorescence-guided surgery in both adult and pediatric populations.

Overall, the findings of the present study are consistent with previously published literature demonstrating that laparoscopic cholecystectomy is a safe and effective surgical procedure when performed with meticulous technique and appropriate intraoperative visualization”. Advances such as fluorescence cholangiography may further improve surgical safety and reduce the incidence of biliary complications in the future.

Laparoscopic cholecystectomy remains the gold standard surgical procedure for the management of gallbladder disease due to its safety, minimal invasiveness, and favorable postoperative outcomes. “The present study demonstrates that with careful operative technique and adherence to established safety principles, laparoscopic cholecystectomy can be performed with a low rate of complications and satisfactory patient recovery. Most patients in this study experienced uneventful postoperative courses and were discharged in stable condition, highlighting the effectiveness of the procedure. Prevention of bile duct injury remains a critical aspect of safe cholecystectomy, emphasizing the importance of clear identification of biliary anatomy during surgery. Recent advancements such as indocyanine green fluorescence cholangiography may further enhance intraoperative visualization and reduce the risk of biliary complications”. Overall, laparoscopic cholecystectomy continues to provide excellent clinical outcomes when performed by experienced surgeons, and the integration of newer imaging technologies may contribute to improved surgical safety and better patient outcomes in the future.

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