Near-infrared fluorescence imaging improves biliary visualization and perioperative outcomes in difficult...

Unclear biliary anatomy is a major contributor to surgical difficulty in laparoscopic cholecystectomy (LC). Near-infrared fluorescence (NIRF) imaging with indocyanine green (ICG) enables real-time visualization of biliary structures; however, its clinical value in difficult LC remains to be fully established. This study aimed to evaluate the impact of NIRF imaging on biliary visualization and surgical outcomes in difficult LC.

A total of 274 patients undergoing difficult LC were retrospectively analyzed (112 ICG, 162 white light [WL]). Perioperative outcomes and intraoperative biliary visualization were compared.

Despite higher surgical difficulty scores in the ICG group (6.0 vs 5.0, P = 0.008), operative time (60.0 vs 75.0 min, P = 0.005) and blood loss (7.5 vs 10.0 ml, P < 0.001) were markedly reduced compared to WL. NIRF markedly improved visualization rates of the common hepatic duct (80% vs 57%, P = 0.010) and cystic duct-common bile duct junction (92% vs 67%, P = 0.003), and shortened visualization times for the cystic duct (1.0 vs 6.0 min, P < 0.001), common hepatic duct (4.5 vs 8.0 min, P = 0.012), and duct junction (4.0 vs 8.5 min, P < 0.001). The benefit of NIRF became more pronounced with the increase of surgical difficulty, while it maintained stable and shorter visualization time compared to WL.

NIRF imaging significantly improves real-time identification of key biliary structures, thus reducing intraoperative blood loss and operation time in difficult LC, even in very difficult cases. The performance of NIRF imaging remains stable across increasing surgical difficulty. These findings are hypothesis-generating and provide quantitative intraoperative data to support the ongoing prospective clinical trial (ChiCTR2400088163).