Design: Prospective single-centre observational study
Population: 96 consecutive laparoscopic cholecystectomies (48 acute cholecystitis, 48 without)
Primary outcome: Simultaneous fluorescence of cystic, common hepatic and common bile ducts
Effect: 16.7% at dissection start, 46.9% before clipping; acute cholecystitis OR 4.48 for common bile duct non-visualisation

A prospective study in Surgical Endoscopy (7 October) followed 96 consecutive laparoscopic cholecystectomies in Japan, half for acute cholecystitis. Every patient received 1.25 mg of indocyanine green (ICG) at induction, and the surgeons recorded whether near-infrared fluorescence showed the cystic, common hepatic and common bile ducts at three points: the start of dissection, the moment the critical view of safety (CVS) was declared, and just before clipping.

The CVS was achieved in 93.8% of cases. Fluorescence showed all three ducts at once in only 16.7% at the start of dissection, rising to 46.9% before clipping. Acute cholecystitis was the only independent predictor of failing to see the common bile duct (OR 4.48) and the common hepatic duct (OR 3.80) before clipping, and failure rose with each Tokyo Guidelines severity grade.

ICG is spreading quickly as an adjunct, and some surgeons are tempted to treat a fluorescent duct as reassurance. This study suggests the signal is weakest in exactly the inflamed gallbladders where bile duct injury is most likely. Use fluorescence as an extra cue, never as a substitute for a properly achieved CVS.

Achieve and document the critical view of safety before clipping, whether or not ICG is used.
Expect fluorescence to show the common ducts less often in acute cholecystitis, and more so in severe grades.
Do not treat absent fluorescence of the common bile duct as evidence that it is clear of the dissection.
Recognise that ICG visibility improves as dissection proceeds, so early images are least informative.
In severe cholecystitis without a clear CVS, move to a bailout strategy rather than relying on fluorescence.

Why it matters

It challenges the assumption that fluorescence makes a difficult cholecystectomy safer, in precisely the cases where it fails most often.

The statistics, in plain English

An odds ratio of 4.48 means the odds of not seeing the common bile duct before clipping were about four and a half times higher with acute cholecystitis. This was a single-centre study of 96 patients, so the exact figures may not transfer to other ICG doses or timing.