L. Policastro1, R. Huang1, P. J. Chung2, H. Patel2, A. Schwartzman2, R. Lee2, G. Sugiyama2 1SUNY Downstate College Of Medicine,Brooklyn, NY, USA 2SUNY Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA
Introduction:
Intraoperative cholangiography using contrast fluid is traditionally a useful visual aid during laparoscopic cholecystectomy, but its disadvantages include increased operative time and exposure to radiation. Recently, near-infrared fluorescent cholangiography using indocyanine green (ICG) dye became available to users of the da Vinci surgical platform. It provides a real-time, 3D endoscopic view highlighting the bile ducts. ICG imaging has been utilized safely and effectively during robotic cholecystectomy. Adequate visualization of biliary structures is paramount in patients presenting with advanced gallbladder disease. This study compares operative results in robotic cholecystectomy with and without the use of ICG at an inner-city academic medical center.
Methods:
Eighty-six patients underwent robotic cholecystectomy between June 2013 and July 2014. Use of fluorescent cholangiography began in November 2013 after FDA approval was obtained. Patients were administered 5 mg of ICG on induction of anesthesia. If there was a failure to visualize biliary anatomy, another 2.5 mg was administered. Both single-site and multiport techniques were used. Patient records were compiled retrospectively.
Results:
There were 46 patients in the non-ICG group and 40 in the ICG group. The groups were similar, except that single-site was utilized more frequently with ICG (73% vs. 48%; p=.02), and chronic cholecystitis was slightly more prevalent in the ICG group (88% vs. 83%; p=.07). Overall, the mean BMI was 30.4 ± 6.5, and the rate of acute cholecystitis was 21%. Use of ICG neither lengthened nor shortened operation time (120 min with, 133 min without; p=.22) or robot time (58 min with, 57 min without; p=.85). The rate of conversion to either open or laparoscopic cholecystectomy was favorable (3% with, 13% without), but to qualify this result, logistic regression was used to account for age, sex, BMI, use of single-site, acute and chronic cholecystitis, tobacco use, and alcohol use. While marginally significant (p=.079), the use of ICG was associated with fewer conversions (OR 0.10, 95% CI 0.008−1.30). There was no difference in post-op length of stay (p=.91).
Conclusion:
ICG fluorescent cholangiography during robotic cholecystectomy enables confident identification of biliary structures without impacting operation time. It is helpful in the training of residents and fellows. It is safe for routine use and may reduce conversions, though its overall cost-effectiveness cannot be concretely established without a large randomized study.
