吲哚菁绿荧光胆道造影在腹腔镜胆囊切除术中的即时应用体会

Real-time application of indocyanine green fluorescence cholangiography during laparoscopic cholecystectomy

目的:探讨吲哚菁绿(ICG)荧光胆道造影在腹腔镜胆囊切除术中即时应用的可行性。方法:收集2020年6月至2020年12月收治的行荧光腹腔镜胆囊切除术的50例患者的临床资料,其中30例通过信封法随机平分至30 min、15 min、0 min 3个时间组中(时间为开始打药至建立气腹完成后镜头初次观察到Calot三角),经外周静脉注射0.5 mg(1 mL 0.5 mg/mL)ICG溶液;余20例术中经胆囊直接注射2 mL 2.5 mg/mL的ICG溶液。观察患者肝外胆道显影时间及显影率。结果:建立气腹完成后镜头初次观察到Calot三角时,开始手术计时。手术开始计时后10 min,经外周静脉注射途径15 min组与30 min组可完全识别胆总管;计时后20 min,3个时间组胆总管均可达到完全显影;15 min组、30 min组Hartmann袋、胆囊颈、胆囊管、胆总管、肝总管显影率差异均无统计学意义(P>0.05)。采集15 min、30 min组初次观察时Calot三角的白光模式及荧光模式图片,对10名肝胆外科的住院医师级别医生进行问卷调查。标记Calot三角区的结构并进行打分,荧光组得分明显优于白光组(P<0.01),15 min、30 min组荧光组得分差异无统计学意义(P>0.05)。术中经胆囊直接注射的20例患者中,15例(75%)肝外胆道即刻显影,成功率较高。失败原因主要为术中穿刺口胆汁渗漏。结论:ICG荧光胆道造影安全、有效,且能即时应用。术前15 min经外周静脉注射、术中经胆囊直接注射两种给药方式均可高效配合临床手术操作,真正做到“即用即打,即打即显”。

Objective:To investigate the feasibility of instant application of indocyanine green(ICG)fluorescence cholangiography in laparoscopic cholecystectomy(LC).Methods:Clinical data of 50 patients receiving fluorescent LC from Jun.2020 to Dec.2020 were collected.Thirty patients were randomly divided into 3 groups(30 min,15 min and 0 min)by envelope-method(these groups were defined according to the duration of the first observation of Calot triangle after the establishment of pneumoperitoneum)and received 0.5 mg(1 mL 0.5 mg/mL)ICG solution by peripheral intravenous injection;In the meantime,2 mL 2.5 mg/mL ICG solution was directly injected through the gallbladder in the other 20 patients during the operation.The time of fluorescence development and the rate of fluorescence development were observed respectively.Results:After the establishment of pneumoperitoneum was completed,the surgical timing started since the Calot triangle was first observed with the lens.The common bile duct could be completely identified in the 15 min group and 30 min group by peripheral intravenous injection at 10 min after the timing of operation.At 20 min after timing,the common bile duct could be fully developed in all three time groups.There were no significant differences in the development rates of Hartmann bag,gallbladder neck,gallbladder duct,common bile duct and hepatic duct between 15 min group and 30 min group(P>0.05).White light mode and fluorescence mode images of Calot triangle were collected in the 15 min and 30 min groups during the initial observation,and a questionnaire survey was conducted among 10 resident doctors in the hepatobiliary department.The structure of the Calot trigonal region was marked and the results were scored.The score of the fluorescence group was significantly better than that of the white light group(P<0.01).Meanwhile,the score of the 15 min and 30 min fluorescence groups was not significantly different(P>0.05).Extrahepatic biliary tract image was developed immediately in 15(75%)of the 20 patients who received direct intraoperative injection of the gallbladder,with a high success rate.The main cause of failure was intraoperative bile leakage at the puncture site.Conclusions:ICG fluorescence cholangiography is safe,effective and readily available.Both peripheral intravenous injection at 15 min before operation and direct injection through the gallbladder during operation can effectively cooperate with clinical operation,truly achieve when needed,medicine can be administered immediately,and imaging can be developed immediately after administration.