Indocyanine Green Fluorescence Imaging During Cholecystectomy: Current Evidence and Optimal Administration for Safe...

Bile duct injury remains a serious complication of cholecystectomy, commonly resulting from misinterpretation of biliary anatomy. Indocyanine green (ICG) fluorescence cholangiography provides real-time visualization of biliary structures and has emerged as a promising tool to reduce this risk. Nonetheless, considerable heterogeneity exists in reported protocols for ICG administration, limiting its widespread standardization. To our knowledge, this is the first study to integrate route, dose, timing, and detection outcomes into a pragmatic clinical framework to guide ICG administration according to specific intraoperative scenarios.

We conducted a systematic analysis of English-language studies published up to December 2024 in PubMed and MEDLINE. Clinical studies evaluating ICG fluorescence in minimally invasive cholecystectomy were included, with specific focus on dose, timing, and route of administration, and their quality was appraised using SIGN and GRADE frameworks.

A total of 54 studies comprising 3070 patients were analyzed. Intravenous administration was the most frequently used route (78%), with preoperative administration times ranging from 15 min to 24 h. Dosing strategies varied, with fixed doses of 2.5 mg and weight-based regimens such as 0.05 mg/kg being the most common. Across studies, high detection rates were reported for the cystic duct (97%), common hepatic duct (96%), and common bile duct (97%). Although intrabiliary administration achieved superior bile duct-to-liver contrast, it was less frequently adopted.

Overall, ICG fluorescence cholangiography enhances biliary visualization and supports safer minimally invasive cholecystectomy, but the lack of standardized administration protocols underscores the need for consensus to optimize its clinical implementation.