Laparoscopic Cholecystectomy Using ICG: Surgical Technique

A presentation on laparoscopic cholecystectomy and its surgical technique. The following topics are covered:

• Anatomy of the biliary tree

• Indications and contraindications for surgery

• Advantages of the method

• Possible complications

• The direct surgical technique used in our clinic, as well as throughout Russia and the world

Relevance and History of the Method

To date, laparoscopic cholecystectomy is the "gold standard" for the treatment of cholelithiasis (gallstone disease). This method has become widespread due to a significant reduction in postoperative complications, shorter hospital stays, and faster patient rehabilitation.

In Russia, the first such operation was performed in 1992 by Professor Galperin. From that moment, an active phase of establishing and developing the technique began. The introduction of new technologies certainly brings certain challenges: the complication rate in our country is approximately 1.5%. At the same time, over 80,000 such interventions are performed annually.

Anatomy and Its Variations

The surgical area is anatomically complex: many important structures pass through it, and damage to them can lead to serious consequences, including disability or death. Therefore, knowledge of anatomy is of paramount importance for the surgeon.

The key dissection zone is Calot's triangle (orange area in the diagram):

• Base facing the liver

• Apex directed toward the confluence of the ducts

• Lateral border – cystic duct

• Medial border – common hepatic duct

• Superior border – cystic artery

Typical anatomy: The right and left hepatic ducts merge to form the common hepatic duct (usually within 2 cm of the inferior surface of the liver). The cystic duct joins it to form the common bile duct, which opens into the duodenum through the sphincter of Oddi.

Anomalies are common, and the surgeon must be prepared for them:

• In 30% of patients, instead of a single right hepatic duct, there are 2–3 bile ducts up to 3 mm in diameter (sectoral or segmental ducts)

• In 5%, transposition of the hepatic ducts is observed, which may cause "visual dissonance" for the surgeon

• In 2% of cases, a hepatocystic duct is present, through which bile from segment V of the liver flows directly into the gallbladder (diameter – fractions of a millimeter)

• Absence of the common hepatic duct may occur – an extremely rare situation where the cystic duct drains directly into the right (or left) lobar duct. This significantly increases the risk of ductal injury during surgery

The cystic duct may join abnormally low, wrap around the common duct, or be completely absent ("saddle gallbladder"), requiring particular care during dissection.

Indications and Contraindications

Indications:

• Chronic calculous cholecystitis

• Acute calculous cholecystitis

• Gallbladder polyps

• Chronic acalculous cholecystitis

• Asymptomatic cholecystolithiasis (large or small stones)

Contraindications:

• Absolute: agonal states, severe cardiopulmonary insufficiency, late pregnancy (risk of pneumoperitoneum effects on the fetus and technical difficulties), malignant involvement of the gallbladder with transmural invasion

• Relative: previous upper abdominal surgeries (severe adhesive disease), metastatic involvement

Important: Gallbladder cancer used to be considered an absolute contraindication to laparoscopy. Current data allow the use of the technique in early stages, but such interventions are performed extremely rarely and only when the process is not advanced.

Advantages of Laparoscopy Over Laparotomy

Laparotomy is a traditional approach through a large incision (right subcostal or midline laparotomy). The laparoscopic method offers distinct advantages:

• Minimal trauma to the anterior abdominal wall (5–10 mm incisions)

• Mild pain syndrome manageable with NSAIDs (ketorolac, analgin)

• Possibility of patient mobilization within a few hours after surgery

• Shorter hospital stays (average 3 days)

• Rapid rehabilitation

• Low risk of postoperative hernias

• Excellent cosmetic effect (barely visible scars)

Complications

Local:

• Bleeding, hematomas

• Infiltrates and abscesses in the subhepatic space

• Obstructive jaundice (residual or "forgotten" stones that have migrated into the common bile duct)

General:

• Pneumonia

• Thromboembolism

• Exacerbation of cardiovascular diseases

Organization of the Operating Process

There are two main schools of staff positioning:

1. French (European): Surgeon stands between the patient's legs, assistant on the left, scrub nurse on the right. Monitors are at the head of the table.

2. American: Two assistants are involved (one holds the camera, the second performs retraction of the gallbladder).

There is no fundamental difference in effectiveness; the choice depends on the surgeon's habits and training.

Equipment and Instruments

Visualization:

• Laparoscope: An angled scope (30°) is used, allowing the viewing angle to be changed

• Monitor: optimal size from 32 inches (in the author's operating room, a 55-inch panel is installed)

• Camera: 4K HD or Full HD. High resolution allows visualization of structures not visible to the naked eye

• LED light source and light cable

Instruments:

• Veress needle for creating pneumoperitoneum

• Trocars: one 10 mm and two 5 mm

• Graspers: "crocodile" (Olmi) and universal (atraumatic) for fixing the gallbladder fundus

• Dissector, scissors (preferably curved)

• Monopolar L-hook

• Clip applier (5 mm) and titanium clips

• Irrigation-aspiration system

• Insufflator

• Coagulator

Stages of the Operation

1. Creation of pneumoperitoneum. A paraumbilical incision up to 1 cm, Veress needle, pressure up to 15 mmHg.

2. Insertion of the first trocar (10 mm). The laparoscope is inserted, and abdominal exploration is performed.

3. Placement of additional trocars (5 mm). Two in the right hypochondrium, one in the epigastrium. Visual control (under laparoscopy).

4. Gallbladder retraction. The fundus is grasped with an atraumatic grasper and retracted toward the diaphragm ("thrown upward"). This provides access to the gallbladder neck and Calot's triangle.

5. Dissection. The surgeon uses a monopolar hook to expose the cystic duct and cystic artery.

6. Clipping and division. Two clips are placed on the proximal portion of the duct and artery, and one clip on the distal portion (closer to the gallbladder). Division is performed with scissors.

7. Mobilization of the gallbladder from the liver bed. Performed with a hook or ultrasonic dissector (in an area away from the main ducts).

8. Gallbladder extraction.

   • In chronic cases: through the 10 mm trocar.

   • In acute cases (enlarged gallbladder): using an endobag. If consumables are unavailable, improvised means may be used.

Critical View of Safety (CVS)

A concept proposed by Strasberg to minimize the risk of major bile duct injury.

Use of Indocyanine Green (ICG technology): The contrast accumulates in the bile, staining the cystic duct and gallbladder (the artery is no longer visualized). When the surgeon sees a clear image of two isolated tubes entering the gallbladder, this is a safety signal. At this stage, the structures can be confidently clipped and divided.