Anatomical S5 segmentectomy for regional cholangitis due to bile duct injury: versatile applications of indocyanine green (with video)

Abstract

Iatrogenic bile duct injury (BDI) is a serious complication that affects patients' quality of life and survival. Surgical resection of the hepatic segment affected has been reported. We describe a case of anatomical resection of segment 5 (S5) using multiple applications of indocyanine green (ICG) fluorescence imaging. A 46-year-old female with BDI during laparoscopic cholecystectomy performed in 2010 was referred to Osaka Metropolitan University Hospital due to recurrent cholangitis. Abdominal computed tomography (CT) scan and magnetic resonance cholangiopancreatography (MRCP) identified stumps on bile duct draining segment 5 (B5s), significantly dilated, suggestive of sclerosing cholangitis. Drainage of B5s was not feasible via endoscopic approach and surgical resection of S5 was indicated. ICG (0.5 mg/kg) was administered 3 days prior to surgery [indocyanine green retention rate at 15 minutes (ICGR15): 3.6%]. After an inverted L-shaped incision, atrophic regions of S5 were identified by naked-eye examination and more clearly by near-infrared imaging. Intraoperative ultrasound also identified biliary dilatations in non-fluorescing regions of S5, which suggested abnormal biliary drainage surrounding the atrophic area. In order to remove whole responsible legions causing cholangitis, we decided to indicate anatomic resection of S5 with the use of positive staining technique. The medial and the cranial branch of S5 portal vein (P5) were punctured and stained (0.25 mg ICG mixed with indigo-carmine). Fluorescence imaging delineated S5, including the atrophic area. Hepatic parenchyma was transected using the clamp-crash method under Pringle maneuver. The two major branches of P5 stained previously were identified and ligated. Finally, the root of the dilated hepatic ducts with complete obstruction were identified and divided, 1 cm distal to metal clips. Fluorescence imaging was used to confirm the removal of all stained regions. Then, ICG (1.25 mg) was administered to confirm blood perfusion of the remaining hepatic parenchyma. No bile leaks were identified by naked-eye examination or fluorescence imaging. Postoperative course was uneventful and patient was discharged on day 8. This technique underscores the multifaceted applications of indocyanine green in liver surgery, from preoperative planning and intraoperative guidance to postoperative assessment, thereby enhancing the safety and efficacy of hepatic resections.

Keywords: Fluorescence-guided surgery; indocyanine green (ICG); liver surgery.

Video 1

Anatomical S5 segmentectomy for regional cholangitis due to bile duct injury: versatile applications of indocyanine green.

Figure 1

Anatomical S5 segmentectomy. (A) Abdominal CT showing atrophic region in S5. (B) Naked-eye visualization of atrophic region. (C) Near infrared fluorescence imaging showing altered biliary drainage after preoperative ICG administration. (D) Segment 5 demarcation after positive staining with ICG and indigo-carmine. (E) State of the liver after S5 segmentectomy. (F) Anatomopathological findings of sclerosing cholangitis. Hematoxylin & eosin, ×40. CT, computed tomography; ICG, indocyanine green.