ICG cholangiography linked to fewer bile duct injuries in 1.27 million cholecystectomies

Design

Retrospective multihospital cohort with inverse probability of treatment weighting

Population

1,266,024 adults undergoing laparoscopic cholecystectomy, US 2016–2024

Primary outcome

Common bile duct injury within 1 year

Effect

0.25% vs 0.40%, RR 0.62 (95% CI 0.49–0.79); conversion RR 0.48 (0.40–0.56)

This JAMA Surgery cohort, published on 1 September, used the Epic Cosmos dataset of US hospitals for 1,266,024 adult laparoscopic cholecystectomies between 2016 and 2024. Indocyanine green (ICG) fluorescence cholangiography was used in 13%, rising from 1.6% in 2016 to 26% in 2024. Robotic cases, cancer surgery and planned open operations were excluded, and weighting adjusted for why surgeons chose ICG.

After weighting, ICG use was associated with fewer common bile duct injuries within a year (0.25% vs 0.40%, RR 0.62), fewer later biliary procedures (RR 0.83), half the conversion rate (0.40% vs 0.84%) and fewer non-biliary complications at 30 days (RR 0.84).

Bile duct injury is too rare for a randomised trial of this size to be practical, so observational data at this scale are the best available. ICG adds a dye injection and a fluorescence-capable laparoscope to the operation. Where the equipment exists, routine use, especially in difficult gallbladders, is supported, alongside the critical view of safety rather than instead of it. In Indian centres without fluorescence systems, this is an argument for procurement, not a reason to delay surgery.

• Consider routine ICG cholangiography where a fluorescence-capable laparoscope is available.
• Use it with the critical view of safety, not as a substitute for it.
• Prioritise it in difficult or inflamed gallbladders, where anatomy is hardest to read.
• Absolute injury rates were low (0.25% vs 0.40%), so explain it as risk reduction, not elimination.
• Record ICG use in the operation note so local audit can track outcomes.

Why it matters

A cheap dye was linked to about a third fewer of surgery's most feared complications, at a scale no trial will reach.

Don't overread it

This was observational; surgeons who use ICG may differ in ways weighting cannot fully capture.

The statistics, in plain English

A relative risk of 0.62 means bile duct injury was about 38% less common with ICG. In absolute terms that is 15 fewer injuries per 10,000 operations (40 down to 25), so roughly 670 operations with ICG for one injury avoided, if the association is causal.

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