Indocyanine green (ICG) fluorescent cholangiography during laparoscopic cholecystectomy using RUBINA™ technology: preliminary experience in two pediatric surgery centers

Abstract

Background: Recently, we reported the feasibility of indocyanine green (ICG) near-infrared fluorescence (NIRF) imaging to identify extrahepatic biliary anatomy during laparoscopic cholecystectomy (LC) in pediatric patients. This paper aimed to describe the use of a new technology, RUBINA™, to perform intra-operative ICG fluorescent cholangiography (FC) in pediatric LC.

Methods: During the last year, ICG-FC was performed during LC using the new technology RUBINA™ in two pediatric surgery units. The ICG dosage was 0.35 mg/Kg and the median timing of administration was 15.6 h prior to surgery. Patient baseline, intra-operative details, rate of biliary anatomy identification, utilization ease, and surgical outcomes were assessed.

Results: Thirteen patients (11 girls), with median age at surgery of 12.9 years, underwent LC using the new RUBINA™ technology. Six patients (46.1%) had associated comorbidities and five (38.5%) were practicing drug therapy. Pre-operative workup included ultrasound (n = 13) and cholangio-MRI (n = 5), excluding biliary and/or vascular anatomical anomalies. One patient needed conversion to open surgery and was excluded from the study. The median operative time was 96.9 min (range 55-180). Technical failure of intra-operative ICG-NIRF visualization occurred in 2/12 patients (16.7%). In the other cases, ICG-NIRF allowed to identify biliary/vascular anatomic anomalies in 4/12 (33.3%), including Moynihan's hump of the right hepatic artery (n = 1), supravescicular bile duct (n = 1), and short cystic duct (n = 2). No allergic or adverse reactions to ICG, post-operative complications, or reoperations were reported.

Conclusion: Our preliminary experience suggested that the new RUBINA™ technology was very effective to perform ICG-FC during LC in pediatric patients. The advantages of this technology include the possibility to overlay the ICG-NIRF data onto the standard white light image and provide surgeons a constant fluorescence imaging of the target anatomy to assess position of critical biliary structures or presence of anatomical anomalies and safely perform the operation.

Keywords: Children; Cholangiography; Cholecystectomy; Fluorescence; Indocyanine green; Technology.

Fig. 1

ICG-NIRF view modes using RUBINA™: overlay (a), monochromatic (b), and intensity map (c)

Fig. 2

The gallbladder (GB), the cystic duct (CD), the common hepatic duct (CHD), the CD–CHD junction, and the common biliary duct (CBD) were easily detected using ICG-FC

Fig. 3

Right hepatic duct (arrow) was visualized using ICG-FC

Fig. 4

Hyperfluorescence of liver background following early administration of ICG (8 h prior to surgery)

Fig. 5

Caterpillar or Moynihan’s hump: a tortuous right hepatic artery (1) and a short cystic artery (2) coming very close to the gallbladder (GB) and cystic duct (CD)

Fig. 6

Supravescicular bile duct (arrow) was discovered intraoperatively using ICG-FC