https://orcid.org/0009-0008-4405-6643
Abstract
Latrogenic bile duct injury remains one of the most severe complications of laparoscopic cholecystectomy, and its surgical repair is technically demanding, particularly in the presence of inflammation and fibrosis. We report the case of a 49-year-old woman who developed obstructive jaundice following a converted laparoscopic cholecystectomy. Cross-sectional imaging demonstrated intrahepatic bile duct dilatation with loss of ductal continuity at the biliary confluence, consistent with a Strasberg E4 injury. Surgical management consisted of a Hepp–Couinaud hepaticojejunostomy guided by indocyanine green fluorescence imaging. Intraoperative fluorescence enabled precise identification of the right and left hepatic ducts, assessment of surrounding tissue perfusion, and confirmation of biliary tree integrity, facilitating reconstruction in a hostile surgical field. The postoperative course was uneventful, with normalization of liver function tests and no biliary complications during follow-up. Indocyanine green fluorescence provided real-time anatomical and functional guidance, representing a safe and valuable adjunct in the surgical reconstruction of complex bile duct injuries.
Introduction
Bile duct injuries (BDIs) represent one of the most severe complications of laparoscopic cholecystectomy, with an incidence ranging from 0.3% to 0.7%, increasing in cases requiring conversion or in the presence of distorted anatomy. Prognosis depends on early detection, accurate anatomical classification, and repair in high-volume hepatobiliary centers [1, 2].
In recent years, indocyanine green (ICG) fluorescence has emerged as a valuable tool for intraoperative visualization of the biliary tree, owing to its ability to emit near-infrared fluorescence following biliary excretion. This enables real-time mapping of biliary anatomy without the need for ionizing radiation or iodinated contrast [2, 3].
Several studies have demonstrated that ICG fluorescence cholangiography improves identification of the cystic duct, common bile duct, and common hepatic duct during laparoscopic cholecystectomy, thereby reducing the risk of bile duct injury and enhancing procedural safety [2–5]. Based on the same principle, its use may also be beneficial during reconstructive surgery for BDIs, facilitating identification of proximal bile ducts and real-time assessment of tissue perfusion [4, 5].
Although its application in this setting remains recent and evidence is largely limited to case reports, ICG has shown value in identifying hepatic ducts, assessing biliary stump viability, and confirming biliary tree integrity. However, there is currently no consensus regarding optimal dosing or timing of administration [3, 6, 7].
We present the case of a patient with a post-cholecystectomy bile duct injury treated with ICG-guided hepaticojejunostomy, highlighting the technical challenges, advantages, and limitations of this approach.
Case presentation
A 49-year-old female with no significant medical history was referred to our center with suspected bile duct injury. Three months earlier, she had undergone a converted laparoscopic cholecystectomy with placement of a drain due to porcelain gallbladder. Her postoperative course was complicated by recurrent abdominal pain, jaundice, and accidental drain removal.
On admission, laboratory findings showed a white blood cell count of 9300/mm3, total bilirubin of 5.4 mg/dL, AST 183 U/L, ALT 244 U/L, and GGT 1547 U/L. Contrast-enhanced abdominal computed tomography revealed intrahepatic biliary dilation and a fluid collection in the gallbladder bed, without vascular involvement. Magnetic resonance cholangiography demonstrated dilated intrahepatic ducts with tapering at the biliary confluence and absence of distal signal, consistent with complete bile duct transection and associated collection (Fig. 1).
Intraoperative images of the right and left bile ducts (arrows and overlying outline). (a) Without indocyanine green. (b) With indocyanine green. (c) Intraoperative cholangiography. (d) Completed hepaticojejunostomy.
Elective surgical repair was planned using ICG-guided hepaticojejunostomy. During anesthetic induction, ICG was administered intravenously at a dose of 0.2 mg/kg, 40 min prior to skin incision.
A right subcostal laparotomy was performed. Intraoperatively, dense inflammatory changes and multiple adhesions were encountered and carefully dissected. A biliary collection in the gallbladder bed was drained and sent for culture. Dissection of the hepatic hilum revealed fibrotic tissue, with identification of the right and left hepatic duct orifices (Fig. 2a), consistent with a Strasberg type E4 injury.
Magnetic resonance cholangiography showing a Strasberg E4 bile duct injury (arrow) and a collection in the gallbladder bed (x).
ICG fluorescence was used to confirm tissue viability and guide proximal duct dissection (Fig. 2b). Intraoperative cholangiography was performed to verify biliary tree integrity (Fig. 2c). The hilar plate was lowered, and both ducts were unified using 6–0 Prolene sutures, creating an anastomotic opening of ~2 cm. An end-to-side hepaticojejunostomy was then performed following the Hepp–Couinaud technique.
The patient had an uneventful postoperative course and was discharged on postoperative Day 5, with normalization of liver function tests and no complications at 7 months of follow-up.
Discussion
ICG fluorescence has significantly impacted intraoperative biliary visualization. Its hepatic excretion and fluorescent properties enable precise identification of biliary structures even in inflamed or fibrotic surgical fields, a common scenario in patients with BDIs [3, 5, 7].
These injuries pose a substantial technical challenge, particularly in the presence of fibrosis or prior infection. Successful reconstruction requires accurate duct identification and a well-perfused anastomosis. In this context, ICG provides a clear advantage by enabling simultaneous visualization of biliary anatomy and tissue perfusion in real time, without radiation exposure [3, 8].
In the present case, ICG administration allowed clear delineation of hepatic ducts and assessment of tissue viability, facilitating identification of anastomotic margins in a hostile surgical field. It also contributed to confirming biliary continuity.
Recent evidence supports this application. Tokuda et al. described successful use of ICG in bile duct injury repair via intraductal administration, allowing duct identification without the need for cholangiography. Ma et al. reported its use for real-time monitoring of biliary-enteric anastomotic perfusion. Recent consensus statements suggest the use of low, repeatable doses for vascular assessment and higher doses administered hours before surgery for biliary mapping, although standardized protocols in this setting are still lacking [3–5].
Key advantages of ICG include the absence of radiation, the ability to perform repeated intraoperative assessments, improved anatomical identification in distorted fields, and objective evaluation of tissue perfusion, which may optimize anastomotic site selection. In our case, conventional cholangiography was used as an adjunct due to the early stage of implementation of this technique.
Limitations include limited tissue penetration (<10 mm), potential background hepatic fluorescence if administered too close to the procedure, and lack of standardized protocols. Additionally, interpretation depends on surgical experience and the imaging system used [3, 4, 7, 9]. In our case, ICG was administered intravenously at a dose of 0.2 mg/kg ~40 min before incision. This timing was selected to allow sufficient hepatic uptake and biliary excretion while maintaining adequate fluorescence intensity for both perfusion assessment and biliary visualization. Previous studies have reported considerable variability in dosing regimens, ranging from 0.025 to 0.5 mg/kg administered between 30 min and 24 h before surgery. Earlier administration generally reduces background hepatic fluorescence and improves bile duct-to-liver contrast, whereas shorter intervals may be advantageous when vascular perfusion assessment is also desired (Table 1).
Indocyanine green dosing and timing strategies for fluorescence-guided biliary surgery.
| Study | Dose | Timing | Purpose |
|---|---|---|---|
| Tokuda et al. | Intraductal | Intraop | Duct identification |
| Ma et al. | 0.25 mg/kg | 30–60 min | Perfusion assessment |
| Akamatsu et al. | 0.05–0.25 mg/kg | 3–24 h | Duct identification |
| Present case | 0.2 mg/kg | 40 min | Duct identification + perfusion |
In this setting, the use of ICG during bile duct reconstruction optimized ductal identification and enabled real-time assessment of tissue perfusion, facilitating a more precise anastomosis in a complex inflammatory field. Beyond this case, the systematic integration of ICG fluorescence may enhance the safety and reproducibility of biliary reconstructive surgery, particularly in the context of distorted anatomy. Although comparative studies are required to determine its impact on long-term outcomes, these findings support its incorporation as a complementary tool in complex hepatobiliary surgery.
Conflicts of interest
None declared.
Funding
None declared.
