Seeing beyond Calot’s triangle: routine indocyanine green fluorescence cholangiography during laparoscopic cholecystectomy - a prospective consecutive single-surgeon study of visualization performance and limitations

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Abstract Purpose To characterise the visualisation performance, limitations, anatomical findings and safety of routine indocyanine green (ICG) fluorescence cholangiography workflow in a consecutive elective and emergency laparoscopic cholecystectomy cohort. This descriptive study was not designed to establish superiority over white-light surgery or intraoperative cholangiography (IOC). Methods Prospectively collected data were analyzed for consecutive adults undergoing elective or emergency laparoscopic cholecystectomy with intended routine ICG fluorescence cholangiography between August 2022 and January 2026 at a UK district general hospital. The intended protocol was ICG 5 mg intravenously at induction of anaesthesia, with fluorescence imaging using the Stryker 1688 Advanced Imaging Modalities platform. Descriptive statistics, confidence intervals, univariable testing and exploratory multivariable logistic regression were used. Results A total of 340 patients were included. Median age was 57.5 years (IQR 41–69) and median BMI was 31.23 kg/m² (IQR 27.04–35.21). The CBD was visualised in 297 patients (87.4%, 95% CI 83.4–90.5), including 262/292 elective cases (89.7%) and 35/48 emergency cases (72.9%). Abnormal biliary anatomy was documented in 29/297 patients with successful CBD visualisation (9.8%); 21 of these were fluorescent ductal structures considered intraoperatively to be consistent with suspected aberrant segment 6/7 ducts. Short cystic duct was documented separately in 22/340 (6.5%). There were no conversions to open surgery, no major bile duct injuries and no documented ICG-related adverse reactions. Three patients (0.9%, 95% CI 0.3–2.6) developed Strasberg type A bile leaks. Cholecystitis, higher BMI and older age were independently associated with unsuccessful CBD visualisation. Conclusion In this uncontrolled prospective consecutive series, routine ICG fluorescence cholangiography was feasible and provided frequent CBD visualisation, while also defining patient and disease factors associated with non-visualisation of CBD. Its value should be interpreted as an adjunct for anatomical orientation rather than evidence of superiority or bile duct injury prevention. Performance was reduced in inflamed and obese patients, reinforcing the need for meticulous dissection, the Critical View of Safety, selective use of other intraoperative imaging when indicated, and established bail-out strategies.

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