Intra-Operative Cholangiography With Indocyanine Green Used to Assess Bile Duct Patency in a Dog With a Ruptured Gallbladder Mucocele

Abstract

In human laparoscopic hepatobiliary surgery, near-infrared fluorescence (NIRF) indocyanine green (ICG) is commonly employed for intraoperative cholangiography to delineate anatomical structures; however, it is not yet used in veterinary medicine. This is the first veterinary case of ICG cholangiography used to confirm common bile duct (CBD) patency in a dog with a ruptured gallbladder mucocele (GBM). A 10-year-old female dog presented with lethargy and anorexia. Blood analysis revealed increased ALT, ALP, GGT, total bilirubin and C-reactive protein levels. Ultrasonography revealed a ruptured GBM. To evaluate CBD patency during surgery, ICG 0.05 mg/kg was injected intravenously 3 h preoperatively. During cholecystectomy, real-time NIRF image of ICG in the CBD showed a filling defect, indicating a partial obstruction within the lumen. After gentle massaging manipulation, CBD patency was confirmed using the NIRF image. No catheterisation or flushing of the CBD was required. The patient showed no relevant clinical signs of biliary stasis 5 months post-surgery. Intraoperative ICG cholangiography efficiently and easily assessed CBD patency in real-time. In this case, CBD patency was achieved by external manipulation with the surgeon's fingers. Therefore, catheterisation or flushing was not necessary. Since enterotomy or cholecystectomy was unnecessary, complications from the leakage of intestinal content or bile were avoided.

Keywords: cholangiography; indocyanine green; intraoperative; near‐infrared fluorescence; patency.

FIGURE 1

Process of exploratory laparotomy. (A) Protruded mucocele from ruptured GBM. (B) Ligation of the cystic duct with PDSII 3‐0 and two clips. (C) Left lateral liver lobe biopsy using the Guillotine method.

FIGURE 2

Intraoperative cholangiography of the patient with GBM. The orange dotted line indicates the hepatic duct and CBD. The green dotted line indicates the duodenum. The yellow arrowhead indicates leakage of ICG in the ruptured GB. (A) A filling defect of ICG was detected, showing a partial obstruction of the bile duct. (B) After external manipulation, the filling defect disappeared, and the patency of the CBD was confirmed. (C) Surgical view of the CBD and duodenum.

FIGURE 3

Resected tissue and histopathology of GB and liver biopsy. (A) Ruptured GB. (B) Liver biopsy of the left lateral liver lobe. (C) In the GB tissue slide, mucosal proliferation, multifocal mucosal ulceration, granulation tissue, accumulated luminal mucins, proteinaceous fluid, haemorrhage, and inflammation were observed. (D) In the liver tissue slide, lymphoplasmacytic and neutrophilic hepatitis, multifocal bile plug formation, bile stasis, biliary proliferation, and intrahepatocytic pigmentation, with extensive neutrophilic and fibrinous peritonitis, were observed.