Novel Use of Intraoperative Fluoroscopy in an Era of ICG for
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Laparoscopic cholecystectomy (LC) is increasingly being used as a first-line treatment for acute cholecystitis. Bile duct injury (BDI) remains the most feared complication of the minimally invasive approach especially in cases with an inflamed calots triangle. Intraoperative Fluoroscopy is an effective and safe treatment option.

While the use of indocyanine dye (ICG) to delineate biliary anatomy serves to reduce BDI, the high cost of the technology prohibits its use in the developing world. Investigators propose a novel use of common bile duct (CBD) stenting preoperatively in cases of cholecystitis secondary to choledocholithiasis as a means of identification and safeguarding the CBD.

A retrospective review was conducted on 22 patients of Grade 2 or Grade 3 cholecystitis who underwent an early LC. All patients were stented preoperatively and the stent was used for much-needed tactile feedback during dissection. A c-arm with intraoperative fluoroscopy was used to identify the CBD prior to clipping of the cystic duct.

The gall bladder was gangrenous in all the cases while two cases had evidence of end-organ damage. This innovative use of CBD stenting allowed correctly delineate biliary anatomy in all of the cases and they report no instances of BDI despite a severely inflamed local environment.

In conclusion, this technique can become a standard of care in all teaching institutions in developing countries further enhancing the safety of cholecystectomy in gangrenous cholecystitis with distorted biliary anatomy.

The Surgery Journal