Application of fluorescent cholangiography during single-incision laparoscopic cholecystectomy for cholecystitis with a right-sided round ligament: Preliminary experience.

An 82-year-old woman was diagnosed with cholecystitis with a right-sided round ligament. We planned a single-incision laparoscopic cholecystectomy. Based on the findings of fluorescent cholangiography, the running course of the common bile duct was confirmed before dissection of Calot's triangle, and the confluence between the cystic duct and the common bile duct was exposed after the dissection of Calot's triangle. The planned surgery was successful. The operative time and intraoperative blood loss were 157 min and 2 mL, respectively. The patient was discharged from our hospital 3 days after surgery. Application of fluorescent cholangiography during a laparoscopic cholecystectomy for the patients with a right-sided round ligament should be widely accepted.

INTRODUCTION

Patients with a right-sided round ligament have many anatomical variations of the bile duct and portal vain.[12] In addition, in such patients, the gallbladder bed is often observed on the left side of the liver, the so-called 'the left-sided gallbladder'.[12] Thus, laparoscopic cholecystectomy for the patient with a right-sided round ligament is technically demanding and requires some technical ingenuity to achieve safely.[2] To avoid biliary injury, intraoperative direct cholangiography is recommended; however, the use of this method for the patients with variations in the biliary anatomy carries a potential risk of biliary injury. Recently, the clinical value of fluorescent cholangiography during a laparoscopic cholecystectomy has been increasingly reported, and this procedure has been deemed comparable to intraoperatively direct cholangiography.[3456]

Herein, we describe our experience with the application of fluorescent cholangiography during a single-incision laparoscopic cholecystectomy for cholecystitis with a right-sided round ligament.

CASE REPORT

An 82-year-old woman had severe upper abdominal pain. According to the images of computed tomography, she was diagnosed with cholecystitis with a right-sided round ligament [Figure 1]. We planned a single-incision laparoscopic cholecystectomy.

Figure 1

Preoperative images. (a and b) Computed tomography with contrast enhancement (a, axial view; b, coronal view) revealed an enlarged gallbladder with gallstones close to the round ligament (a). In addition, the gallbladder bed covered the round ligament from right to left (b). According to these findings, the patient was diagnosed with cholecystitis with a right-sided round ligament. Black broken arrow, the round ligament; black solid arrows, the gallbladder bed

Based on our previous reports,[56789] a single-incision laparoscopic cholecystectomy was performed. After a single 2–2.5-cm long, vertical incision was made across the umbilicus; the SILS-Port (Covidien, Mansfield, MA, USA) was placed through the umbilical incision. A 5-mm flexible scope (Olympus, Tokyo, JAPAN) was inserted through the port to explore the abdominal cavity through a 12-mmHg pneumoperitoneum produced with carbon dioxide. An additional pair of 5-mm forceps was inserted through the umbilical incision outside the SILS-Port to lift the fundus of the gallbladder.

According to our previous report,[56] fluorescent cholangiography was performed. As a fluorescent source, 1 mL of indocyanine green (2.5 mg/mL of Diagnogreen; Diichi Sankyo Co., Tokyo, Japan) was intravenously injected after endotracheal intubation of the patient in the operating room. A D-light P-light-source unit (Karl Storz Endoskope, Tuttlingen, Germany) with the ability to alternate between a xenon and infrared light using a foot pedal served as a laparoscopic fluorescence imaging system through a 12-mm port inside of the SIIS-Port. A filter was placed on a 30°, 10-mm laparoscope, which, when activated, captured only the fluorescent image reflected by the dye.

Before dissection of Calot's triangle, the running course of the common bile duct was identified under fluorescent cholangiography [Figure 2]. After dissection of Calot's triangle, the confluence between the cystic duct and common bile duct was successfully visualised [Figure 3]. The resection line of the cystic duct was determined according to the findings of fluorescent cholangiography [Figure 3b]. The cystic artery and the cystic duct were cut using 2–3 clips after obtaining a 'critical view of safety'.[10] Once the gallbladder was dissected from the gallbladder bed, the specimen inside the retrieval bag was removed through the umbilical incision. The umbilical incision was carefully closed without placing any drainage tubes.

Figure 2

Intraoperative findings before dissection of Calot's triangle. (a) Under a normal laparoscopic view, the gallbladder bed covered the round ligament from right to left, and the running course of the common bile duct could not be identified. Thick fat tissue due to cholecystitis covered the gallbladder and Calot's triangle. (b) Under fluorescent cholangiography, the running course of the common bile duct was visualised before dissection of Calot's triangle. Black broken arrow, the round ligament; black solid arrows, the gallbladder bed; white broken arrows, the running course of the common bile duct

Figure 3

Intraoperative findings after dissection of Calot's triangle. (a) Under normal laparoscopic view, the running course of the cystic duct was identified after the dissection of Calot's triangle. (b) Under fluorescent cholangiography, the confluence between the cystic duct and the common bile duct was identified. White broken arrows, the running course of the common bile duct; white solid arrows, the running course of the cystic duct; white arrowheads, the confluence between the cystic duct and the common bile duct

The planned surgery was successful. The operative time and intraoperative blood loss were 157 min and 2 mL, respectively. The patient was discharged from our hospital 3 days after surgery.

DISCUSSION

In the patients with a right-sided round ligament, the gallbladder bed is often observed on the left side of the liver. Thus, the neck of the gallbladder is observed above the common bile duct.[12] Accordingly, inflammation around the neck of the gallbladder easily involves the common bile duct; therefore, confirmation of the boundary between the common bile duct and the neck of the gallbladder including the cystic duct lapses into an adverse situation. To conquer such a situation, according to the previous reports of laparoscopic cholecystectomy for the patients with a right-sided round ligament, the fundus-first and dome-down resection procedure are recommended for the avoidance of biliary injury but is a demanding procedure.[2] In contrast, the application of fluorescent cholangiography is a safe and easy procedure to confirm the running course of the common bile duct with no risk of biliary injury. After confirmation of the running course of the common bile duct, dissection of Calot's triangle can be safely initiated [Figure 2].

During dissection of Calot's triangle in the patients with a right-sided round ligament, fluorescent cholangiography can be easily repeated with no biliary injury. In contrast, intraoperative direct cholangiography has a potential risk of biliary injury given the requirement of cutting the cystic duct. These facts reveal that fluorescent cholangiography is superior to intraoperative direct cholangiography. According to our previous report,[56] thick fat tissue avoids the identification of biliary anatomy under fluorescent cholangiography; therefore, a meticulous procedure under repeating fluorescent cholangiography is required to prevent biliary injury. Consequently, the so-called 'critical view of safe' can be obtained after dissection of Calot's triangle even in patients with a right-sided round ligament [Figure 3].

CONCLUSION

The application of fluorescent cholangiography during single-incision laparoscopic cholecystectomy for cholecystitis with a right-sided round ligament is an easy and suitable procedure. The clinical value of fluorescent cholangiography during laparoscopic cholecystectomy for the patients with other variations in biliary anatomy requires further investigation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.