Use of indocyanine green in complex biliary reconstruction for Strasberg E4 injury

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.