Delayed Laparoscopic Cholecystectomy With Fluorescent Cholangiography for Acute Cholecystitis: Is It Safe?

Abstract

Background: According to the Tokyo Guidelines 2018 (TG-18), delayed laparoscopic cholecystectomy (DLC) after recovering from acute cholecystitis (AC) is recommended for patients with poor status. Moreover, DLC for patients with good status remains controversial, and TG-18 does not include clinical questions regarding fluorescent cholangiography (FC). In this study, we evaluated the clinical value and safety of FC during DLC.

Methods: We performed DLC in 226 patients after recovering from AC. The electronic medical records of these patients were retrospectively reviewed, focusing on preoperative assessment and intraoperative and postoperative outcomes. Biliary and/or arterial injuries were treated as intraoperative complications.

Results: Of the study patients, 144 underwent DLC with FC. Among the remaining 82 patients who underwent DLC without FC, the rate of intraoperative complications was 7.3% (n = 6), which was significantly higher than in those who underwent DLC with FC (0%) (p = 0.002). The rate of conversion to open cholecystectomy during DLC with FC (1.4%) was significantly lower than that during DLC without FC (15.9%). The mean operative time was not significantly different between the patients who underwent DLC with and without FC (p = 0.503). The mean blood loss and postoperative complications in patients who underwent DLC with FC were significantly lower than those who underwent DLC without FC (p = 0.041 and p = 0.002, respectively).

Conclusions: Utilizing FC can reduce intraoperative and postoperative complications, the conversion rate, and blood loss during DLC; therefore, DLC with FC is recognized as a safe procedure for patients with AC.

Keywords: acute cholecystitis; delayed laparoscopic cholecystectomy; fluorescent cholangiography; percutaneous transhepatic gallbladder drainage; single‐incision laparoscopic cholecystectomy.

FIGURE 1

Intraoperative findings of the “critical view of safety.” (A) Normal laparoscopic view after dissection of Calot's triangle showing that the cystic duct (CD) and the cystic artery (CA) were exposed, resulting in a “critical view of safety.” (B) Fluorescent cholangiography showing the CD, the common bile duct (CBD), and the gallbladder (GB) is well visualized.

FIGURE 2

Intraoperative findings of the fundus‐down procedure. (A) Normal laparoscopic view before dissection of Calot's triangle revealed that dissection of Calot's triangle could not be performed due to severe inflammation around the gallbladder neck, but the connective tissue around the gallbladder fundus was mildly inflamed; therefore, the fundus‐down approach was selected. (B) Normal laparoscopic view after the fundus‐down approach illustrates that the cystic artery cannot be exposed from the connective tissue around the cystic duct (CD). (C) Fluorescent cholangiography after the fundus‐down approach shows that the CD and the common bile duct (CBD) are well visualized. (D) The CD and the cystic artery were divided together via an endoscopic linear stapler.

FIGURE 3

Intraoperative findings of subtotal cholecystectomy. (A) Normal laparoscopic view during dissection of Calot's triangle showing that the critical view of safety could not be achieved due to severe inflammation in Calot's triangle. (B) Fluorescent cholangiography depicting the cystic duct (CD), the common bile duct (CBD), and the gallbladder (GB) neck. (C) The GB neck was divided via an endoscopic linear stapler. (D) The staple line was at the stump of the GB neck, with visualization of the CD and the CBD under fluorescent cholangiography.

FIGURE 4

Intraoperative findings of the previous division of the cystic artery (CA) before achieving the critical view of safety. (A) Normal laparoscopic view showing that the CA could be exposed, but dissection of Calot's triangle could not be continued due to severe inflammation in Calot's triangle. (B) Fluorescent cholangiography revealed that the running courses of the cystic duct (CD) and the common bile duct (CBD) were well visualized, but the confluence of the CD and the gallbladder (GB) could not be visualized because of the CA. (C) The CA was divided using a 5‐mm clip. (D) The confluence of the CD and the GB was well visualized after the previous division of the CA under the guidance of fluorescent cholangiography.

FIGURE 5

Intraoperative findings of previous division of the cystic duct (CD) before achieving the critical view of safety. (A) Normal laparoscopic view during dissection of Calot's triangle revealed that the CD could be exposed, but the connective tissues at the caudal side of the gallbladder neck could not be dissected due to severe inflammation. (B) Normal laparoscopic view showing that the cystic artery (CA) could not be found at the cranial side of the gallbladder neck. (C) Fluorescent cholangiography showed that the CD and the common bile duct (CBD) were well visualized. (D) The CA could be clipped with no injury to the right hepatic artery (RHA) in the connective tissue at the caudal side of the gallbladder neck after the previous division of the CD under the guidance of fluorescent cholangiography.

FIGURE 6

Change in the cystic duct (CD) from undetectable before dissection of Calot's triangle to detectable during dissection of Calot's triangle under fluorescent cholangiography. (A) Normal laparoscopic view showing severe inflammation in Calot's triangle. (B) Fluorescent cholangiography revealed that the gallbladder (GB) and the common bile duct (CBD) were well visualized, but the CD was undetectable. (C) Normal laparoscopic view showing that it was difficult to achieve a safe critical view. (D) Fluorescent cholangiography indicated that the CD was detectable with good visualization of the GB, and the CBD was visualized during the dissection of Calot's triangle.