BDI is an unavoidable challenge in biliary surgery, with the incidence of iatrogenic, attributed to the widespread application of laparoscopic hepatobiliary surgery. The incidence of LC-related iatrogenic BDI has been reported to be as high as 0.3–0.7% in foreign literature [5, 6]. Complex hepatolithiasis surgery typically involves re-exploration of the hepatobiliary tract due to prior hepatobiliary stone surgeries or other upper abdominal surgeries, such as gallbladder surgery (open cholecystectomy, recurrent stones after laparoscopic minimally invasive cholecystolithotomy, biliary stones after LC), open or laparoscopic CBD exploration with T-tube drainage, and other upper abdominal surgeries like gastric, duodenal, and transverse colon surgeries [7, 8]. Intra-abdominal adhesions, particularly severe adhesions of the hepatic portal tissues, are the primary challenge with repeat abdominal surgery because they can hinder the identification of the CBD during surgery, predisposing the patient to BDI and other injuries [9]. Hence, precise identification of bile ducts during surgery is imperative to prevent BDI. ICG fluorescence navigation technology has gained prominence in hepatobiliary surgery. ICG is a fluorescent dye that emits fluorescence when bound to proteins and exposed to near-infrared light, serving as a navigational aid during surgery. Following intravenous injection, ICG rapidly and completely binds to plasma proteins, albumin, and lipoproteins and is selectively absorbed by the liver and excreted via bile secretion [10, 11]. Its rapid excretion confers safety, minimal side effects, and non-interference in bodily reactions, thus making it advantageous [12]. ICG technology is becoming increasingly mature and is widely employed in the medical field. Its applications in hepatobiliary surgery encompass tumor localization, boundary delineation, liver staining segmentation, and visualization of biliary structures, thereby reducing surgical risks and complications [10, 13]. Notably, ICG fluorescent navigation technology has enabled real-time visualization of the biliary anatomy during LC and other complex biliary surgeries, thereby reducing the incidence of iatrogenic BDI [14, 15]. Furthermore, ICG facilitates clear visualization of biliary structures during procedures such as LCBDE, repeat CBD exploration, and complex hepatolithiasis surgeries, effectively reducing complications such as biliary duct injury and enhancing surgical efficiency due to its safety and high efficiency [3, 6, 10, 16].
In this study, we employed ICG fluorescent navigation technology to conduct LCBDE for complex hepatolithiasis. This advanced technology enables real-time visualization of the biliary system, eliminates the requirement for anatomical separation of the first hepatic portal and hepatoduodenal ligament, and facilitates efficient identification and separation of the bile ducts. Consequently, it improves bile duct recognition rates, reduces the need for conversion to open surgery, and enhances surgical precision by minimizing excessive dissection and reducing trauma to surrounding tissues, such as the gastrointestinal tract. Our results indicated that the observation group experienced significantly shorter times for locating bile ducts, operation duration, conversion to open surgery, bile leakage, abdominal infection, postoperative bleeding, and residual stone cases than the control group, with statistically significant differences (P < 0.05). Furthermore, the recovery time for bowel function, drainage tube removal, and hospital stay group were significantly shorter in the observation than in the control group, with statistically significant differences (P < 0.05). This indicates faster postoperative recovery and shorter hospital stay in the observation group. However, there were fewer gastrointestinal fistula and pancreatitis cases in the observation group than in the control group, without a statistically significant difference (P > 0.05), possibly due to the limited sample size. Nevertheless, this finding suggests that fluorescent laparoscopy can reduce gastrointestinal and pancreatic injuries to a certain extent. Over the past decade, ICG fluorescent navigation technology has advanced significantly in hepatobiliary surgery and has demonstrated its applicability in various other surgical procedures, such as lymph node dissection around gastrointestinal tumors, evaluation of colon anastomotic perfusion, bariatric surgery, urology, and gynecological surgeries [17]. However, ICG fluorescent imaging has certain limitations. First, the lack of unified standards and consensus on ICG dosage, concentration, administration route, and timing necessitates multi-center, large-sample studies. Second, a major drawback is the limited imaging depth of approximately 10 mm, resulting in poor visualization in cases where the thickness of adhesive tissue on the bile duct surface exceeds 10 mm [13]. The limitations of this study include being single-centered and having a relatively small sample size. We would recommend that a high-quality, multicenter, randomized clinical trial is developed specifcally to further evaluate the safety and effectiveness in this enriched population. Current research focuses on optimizing imaging technology to improve fluorescent navigation effects in complex hepatolithiasis surgeries [18].
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