DOI: 10.26820/recimundo/9.(2).abril.2025.710-723

URL: https://recimundo.com/index.php/es/article/view/2679

EDITORIAL: Saberes del Conocimiento

REVISTA: RECIMUNDO

ISSN: 2588-073X

TIPO DE INVESTIGACIÓN: Artículo de revisión

CÓDIGO UNESCO: 32 Ciencias Médicas

PAGINAS: 710-723

Use of indocyanine green (ICG) uorescence in laparoscopic

surgery: benets in anatomical identication and prevention

of biliary injuries. A systematic review

Uso de la ﬂuorescencia con verde de indocianina (ICG) en cirugía

laparoscópica: beneﬁcios en la identiﬁcación anatómica y la prevención

de lesiones biliares. Una revisión sistemática

Utilização da ﬂuorescência do verde de indocianina (ICG) na cirurgia

laparoscópica: benefícios na identiﬁcação anatómica e prevenção de

lesões biliares. Uma revisão sistemática

Adriana Stephania Chancusig Reinoso

; Alejandro Solis Vinueza

; Julio David Salgado Cedeño

;

Nelson Francisco Villagómez Albán

RECIBIDO: 10/03/2025 ACEPTADO: 19/04/2025 PUBLICADO: 06/07/2025

1. Médica Cirujana; Directora Adjunta en el Healthy Medic Center - Especialidades Médicas y Odontológicas; Quito, Ecuador; md.adria-

nachr@gmail.com; https://orcid.org/0009-0003-6149-0613

2. Especialista en Cirugía General y Laparoscópica; Fellowship de Laparoscopia Avanzada y Cirugía Bariátrica; Médico; Jefe de Ci-

rugía General en el Hospital Básico El Ángel, Jefe de Cirugía General en el Hospital Básico San Gabriel; Jefe de Servicio General

en la Clínica Santa Lucia; Director en Laparascopic Center; Quito, Ecuador; solisvinuezaalejandro@gmail.com; https://orcid.

org/0009-0008-9316-1175

3. Magíster en Gerencia Hospitalaria y Administración de Hospitales; Médico Cirujano; Auditor Médico en Novaclínica S.A.; Quito,

Ecuador; jdscedeno1997@gmail.com; https://orcid.org/0009-0003-0799-0799

4. Médico Cirujano; Kaplan Medical Center; New Jersey, Estados Unidos; franciscovillagomeza@gmail.com; https://orcid.org/0000-

0002-4541-7948

CORRESPONDENCIA

Adriana Stephania Chancusig Reinoso

md.adrianachr@gmail.com

Quito, Ecuador

ABSTRACT

The objective of this study is to discuss the use of indocyanine green (ICG) ﬂuorescence in laparoscopic surgery, as well as its beneﬁts

in anatomical identiﬁcation and the prevention of biliary injuries. We delve deeply into topics related to laparoscopy and the risk of biliary

injuries, factors predisposing to the development of biliary lithiasis, the Amsterdam classiﬁcation describing bile leaks and strictures, the

use of ICG ﬂuorescence in laparoscopic surgery, and an introduction to ICG technology. Regarding the methodological guidelines, this

study was characterized as a PRISMA-type systematic review. Inclusion and exclusion criteria were applied, along with keywords in both

English and Spanish, to construct search strings for databases such as Google Scholar, SciELO, and Elsevier. Finally, it was concluded

that the administration of indocyanine green (ICG) ﬂuorescence in laparoscopic surgery is highly useful. It is an efﬁcient method that aids

in the precise, real-time visualization of anatomical structures of the biliary ducts, the cystic duct, and blood vessels, thereby reducing

the probability of accidental injuries to the biliary tree and other surrounding tissues. Within the surgical process, it allows the surgeon to

perform dissection precisely, avoiding iatrogenic injuries due to the clear identiﬁcation of anatomical structures, which prevents compli-

cations during surgery.

Keywords: Laparoscopic surgery, Laparoscopy, Indocyanine green, ICG, Fluorescence, Fluorescent imaging.

RESUMEN

El objetivo de este estudio es analizar el uso de la ﬂuorescencia con verde de indocianina (ICG) en la cirugía laparoscópica, así como sus

beneﬁcios en la identiﬁcación anatómica y la prevención de lesiones biliares. Profundizamos en temas relacionados con la laparoscopia

y el riesgo de lesiones biliares, los factores que predisponen al desarrollo de litiasis biliar, la clasiﬁcación de Ámsterdam que describe las

fugas y estenosis biliares, el uso de la ﬂuorescencia ICG en la cirugía laparoscópica y una introducción a la tecnología ICG. En cuanto a

las pautas metodológicas, este estudio se caracterizó como una revisión sistemática de tipo PRISMA. Se aplicaron criterios de inclusión

y exclusión, junto con palabras clave en inglés y español, para construir cadenas de búsqueda para bases de datos como Google

Scholar, SciELO y Elsevier. Finalmente, se concluyó que la administración de ﬂuorescencia con verde de indocianina (ICG) en la cirugía

laparoscópica es muy útil. Se trata de un método eﬁcaz que ayuda a visualizar con precisión y en tiempo real las estructuras anatómicas

de los conductos biliares, el conducto cístico y los vasos sanguíneos, lo que reduce la probabilidad de lesiones accidentales en el árbol

biliar y otros tejidos circundantes. Dentro del proceso quirúrgico, permite al cirujano realizar la disección con precisión, evitando lesiones

iatrogénicas gracias a la clara identiﬁcación de las estructuras anatómicas, lo que previene complicaciones durante la cirugía.

Palabras clave: Cirugía laparoscópica, Laparoscopia, Verde de indocianina, ICG, Fluorescencia, Imágenes ﬂuorescentes.

RESUMO

O objetivo deste estudo é discutir o uso da ﬂuorescência do verde de indocianina (ICG) na cirurgia laparoscópica, bem como os seus

benefícios na identiﬁcação anatómica e na prevenção de lesões biliares. Aprofundamos temas relacionados à laparoscopia e ao risco

de lesões biliares, fatores predisponentes ao desenvolvimento de litíase biliar, a classiﬁcação de Amsterdã que descreve vazamentos e

estenoses biliares, o uso da ﬂuorescência ICG na cirurgia laparoscópica e uma introdução à tecnologia ICG. No que diz respeito às dire-

trizes metodológicas, este estudo foi caracterizado como uma revisão sistemática do tipo PRISMA. Foram aplicados critérios de inclusão

e exclusão, juntamente com palavras-chave em inglês e espanhol, para construir cadeias de pesquisa para bases de dados como Goo-

gle Scholar, SciELO e Elsevier. Finalmente, concluiu-se que a administração da ﬂuorescência do verde de indocianina (ICG) na cirurgia

laparoscópica é altamente útil. É um método eﬁciente que auxilia na visualização precisa e em tempo real das estruturas anatómicas dos

ductos biliares, do ducto cístico e dos vasos sanguíneos, reduzindo assim a probabilidade de lesões acidentais na árvore biliar e outros

tecidos circundantes. Dentro do processo cirúrgico, permite ao cirurgião realizar a dissecção com precisão, evitando lesões iatrogénicas

devido à identiﬁcação clara das estruturas anatómicas, o que previne complicações durante a cirurgia.

Palavras-chave: Cirurgia laparoscópica, Laparoscopia, Verde de indocianina, ICG, Fluorescência, Imagem ﬂuorescente.

712

RECIMUNDO VOL. 9 N°2 (2025)

Introduction

Indocyanine green (ICG) ﬂuorescence for

laparoscopic surgery, is a tool helps to im-

prove the visualization, safety of this type

of surgical procedures, because it can be

seen with greater precision all anatomical

structures of the biliary tree, facilitates the

distinction of bile ducts, blood vessels, cys-

tic duct avoiding the probability of iatrogenic

injuries. Even ICG, allows detection of senti-

nel lymph nodes in oncological surgery, the

identiﬁcation of tumors and the evaluation of

tissue viability (1).

It is opportune to point out that indocya-

nine green (ICG) according to what was

described by Pérez et al (2) is a drug that

is used in medicine to evaluate tissue per-

fusion during surgical procedures. Its ﬂuo-

rescent properties allow it to be visualized

with infrared probes, which makes it useful

to visualize vascular structures and evaluate

blood circulation in different tissues. It is ad-

ministered intravenously and is distributed

rapidly through highly vascularized sites due

to its afﬁnity for plasma proteins. Indocyani-

ne green can have adverse reactions, but

in general the possibility of serious or lethal

events is low, which makes it a safe option

for intraoperative use. Its process of hepatic

metabolization and biliary excretion makes

it especially useful in hepatobiliary-pancrea-

tic surgeries where clarity about the structu-

res of the biliary tree is required, iatrogenic

injuries of the biliary tract are a considerable

challenge, with an incidence of 0.4-0.6% in

laparoscopic cholecystectomy.

Likewise, Pérez et al (2) indicate that the

chemical formula of indocyanine green is:

C43 H47 N2 NaO6 S2 is a complex orga-

nic compound that belongs to the cyanine

family. Its molecular structure includes two

indolenine rings joined by a conjugated car-

bon chain, which gives it its ﬂuorescence

properties. Molecular weight: 774.97 g/mol.

Color: Intense green. Fluorescent proper-

ties: Emits near-infrared light when excited

with visible light. Solubility: Soluble in water

CHANCUSIG REINOSO, A. S., SOLIS VINUEZA, A., SALGADO CEDEÑO, J. D., & VILLAGÓMEZ ALBÁN, N. F.

and in some polar organic solvents. Indoc-

yanine green is a ﬂuorescent tricarbocyani-

de stain visible with near-infrared light or by

laser systems, with absorption and emission

peaks of 805-835nm, respectively. Fluores-

cence is detected through the use of speci-

ﬁc cameras that transmit this signal to a mo-

nitor, through which the structures in which

the stain is found can be identiﬁed, which

was approved by the Food and Drug Admi-

nistration in 1956.

The present document makes mention of the

use of ﬂuorescence with indocyanine green

(ICG) in laparoscopic surgery and the be-

neﬁts in anatomical identiﬁcation and pre-

vention of biliary injuries. Similarly, aspects

related to laparoscopy and the risk of biliary

injuries, factors that predispose to the de-

velopment of biliary lithiasis, the Amsterdam

classiﬁcation, which describe biliary leaks

and strictures, use of ﬂuorescence with in-

docyanine green (ICG) in laparoscopic sur-

gery and Introduction to ICG technology:

how it works, physiological basis.

Methodology

The methodology of the present investiga-

tion is a PRISMA systematic review, on "Use

of indocyanine green (ICG) ﬂuorescence in

laparoscopic surgery: beneﬁts in anatomical

identiﬁcation and prevention of biliary inju-

ries." For which an exhaustive search was ca-

rried out in databases such as Google Scho-

lar, Scielo, and Elsevier, applying keywords

both in English (Laparoscopic surgery OR

Laparoscopy) AND (Indocyanine green OR

ICG) AND (Fluorescence OR Fluorescent

imaging) AND (Anatomical identiﬁcation OR

Anatomical landmarks) AND (Biliary injury

OR Bile duct injury OR Biliary complications)

as well as in Spanish (Cirugía laparoscópi-

ca OR Laparoscopia) AND (Verde de indo-

cianina OR ICG) AND (Fluorescencia OR

Imagen de ﬂuorescencia) AND (Identiﬁca-

ción anatómica OR Referencias anatómicas)

AND (Lesión biliar OR Lesión de vía biliar

OR Complicaciones biliares). Inclusion and

Exclusion Criteria. Among the inclusion cri-

713

RECIMUNDO VOL. 9 N°2 (2025)

USE OF INDOCYANINE GREEN (ICG) FLUORESCENCE IN LAPAROSCOPIC SURGERY: BENEFITS IN ANA-

TOMICAL IDENTIFICATION AND PREVENTION OF BILIARY INJURIES. A SYSTEMATIC REVIEW

teria selected were: bibliographic references

from the last 5 years (2020-2025), research

papers both in English and Spanish, that ad-

dress the subject matter of the investigation.

For which the title of the work was read in the

ﬁrst instance, then the abstract was read in

a second moment, and ﬁnally, as a deﬁnitive

discarding or inclusion process, the conclu-

sion. As exclusion criteria were discarded:

bibliography not within the established range

(with the exception of some research article

whose information is very relevant for the pre-

sent work), bibliography that addresses a di-

fferent subject matter from the central objec-

tive of the present investigation, bibliography

in languages other than English or Spanish,

repeated bibliographies, bibliographies wi-

thout open access. The summary of the ar-

ticles found in the database is summarized

in Table 1. As well as in Table 2, the selected

articles are presented after applying the in-

clusion and exclusion criteria.

Table 1. Summary of articles found in database

Database

Selected articles

Google Scholar

Scielo

Elsevier

Total

Amsterdam

Classification

Description

Strasberg

Classification

Description

Type A

Minor bile leak affecting

peripheral ducts (cystic,

terminal ducts, or Luschka)

Type A

Inadvertent cut of the

cystic duct

Type B

Major bile leak affecting

main ducts (common bile

duct, common hepatic,

right or left hepatic), with

or without stricture

Type B

Inadvertent cut of the

cystic duct with injury

to the common hepatic

duct or common bile

duct

Type C

Bile duct stricture without

leak

Type C

Inadvertent cut of the

common hepatic duct

or common bile duct

Type D

Duct section or resection,

with or without surgical

ligation or stapling.

Type D

Inadvertent cut of the

right or left bile duct

Classification of Biliary Leaks

Type E

Laceration of the

biliary tract.

Low-Grade

Biliary Leaks

Become evident after opacifying the intrahepatic biliary tree

High-Grade

Biliary Leaks

Are evident before opacifying the intrahepatic biliary tract.

Database

Articles found

Google Scholar

Scielo

Elsevier

Total

115

Table 2. Selection of primary articles after applying the inclusion and exclusion criteria

Database

Selected articles

Google Scholar

Scielo

Elsevier

Total

Amsterdam

Classification

Description

Strasberg

Classification

Description

Type A

Minor bile leak affecting

peripheral ducts (cystic,

terminal ducts, or Luschka)

Type A

Inadvertent cut of the

cystic duct

Type B

Major bile leak affecting

main ducts (common bile

duct, common hepatic,

right or left hepatic), with

or without stricture

Type B

Inadvertent cut of the

cystic duct with injury

to the common hepatic

duct or common bile

duct

Type C

Bile duct stricture without

leak

Type C

Inadvertent cut of the

common hepatic duct

or common bile duct

Type D

Duct section or resection,

with or without surgical

ligation or stapling.

Type D

Inadvertent cut of the

right or left bile duct

Classification of Biliary Leaks

Type E

Laceration of the

biliary tract.

Low-Grade

Biliary Leaks

Become evident after opacifying the intrahepatic biliary tree

High-Grade

Biliary Leaks

Are evident before opacifying the intrahepatic biliary tract.

Database

Articles found

Google Scholar

Scielo

Elsevier

Total

115

714

RECIMUNDO VOL. 9 N°2 (2025)

Figure 1. Flow Diagram of Selected Studies

Results

It is worth noting that during laparoscopic

cholecystectomy procedures, injuries to the

bile ducts can occur, and these can vary in

their level of severity according to Davila et al

(10). These injuries are produced during any

surgical procedure and can occur in any part

of the biliary tract and comprise 95% of be-

nign strictures of the biliary tract. The Bismu-

th and Strasberg classiﬁcations are impor-

tant tools to evaluate and classify bile duct

injuries in laparoscopic cholecystectomy and

provide crucial information about the loca-

tion, extent, and severity of the injuries, which

guides surgical planning and helps in the

prognosis and treatment of affected patients.

In relation to the conﬂuence of the hepatic

ducts, Davila et al (10) express that it is very

frequent in this surgical intervention, having

several classiﬁcations, the most common

being type III and type I of the Bismuth clas-

siﬁcation. These compromise the vessels

and pedicle, with their treatment being bi-

lioenteric anastomosis with Roux-en-Y with

a mortality rate of 5%.

It is opportune to indicate that laparoscopic

cholecystectomy is a procedure that seeks

to minimize incisions to reduce the risk of

BDI (Biliary Duct Injury), but its application

requires caution on the part of medical per-

sonnel. Likewise, Rojas & Vera (7) indicate

that factors such as obesity and aging in-

crease the risk, and key strategies such as

surgical meticulousness, adequate interpre-

tation of anatomical variants, and conversion

to open procedures are essential to prevent

these injuries. Common errors involve a mi-

sinterpretation of anatomy, especially the

confusion of the hepatic duct with the cys-

tic or other factors such as inﬂammation in

Calot's triangle, short cystic duct, excessive

cephalic retraction, lateral retraction, and

excessive tension at the choledocho-cystic

junction contribute to BDI.

For Rojas & Vera (7), it is considered that

prompt identiﬁcation and treatment of these

injuries are crucial to mitigate possible com-

plications, such as biliary ﬁstulas, intra-ab-

dominal abscesses, strictures, recurrent

cholangitis, and secondary biliary cirrhosis

CHANCUSIG REINOSO, A. S., SOLIS VINUEZA, A., SALGADO CEDEÑO, J. D., & VILLAGÓMEZ ALBÁN, N. F.

715

RECIMUNDO VOL. 9 N°2 (2025)

or stricture up to portal hypertension and

cirrhosis; they encompass multiple classiﬁ-

cations grouping these injuries according to

their location and extent. In this context, the

aim is to review and update the risk factors,

types of biliary tract injuries, and treatment

approaches related to these complications.

Similarly, Rojas & Vera (7) mention two clas-

siﬁcation systems used in the medical ﬁeld

to categorize different types of complications

related to the biliary tract during surgical pro-

cedures. In the Amsterdam classiﬁcation,

four types (A, B, C, and D) are identiﬁed that

describe bile leaks and strictures, specifying

the location and severity of the ductal invol-

vement. On the other hand, the Strasberg

classiﬁcation also addresses situations in

which an inadvertent cut of the cystic, hepa-

tic, and common bile ducts occurs, catego-

rizing them as types A, B, C, D, and E, the

latter referring to biliary tract laceration.

Table 3. Amsterdam Classiﬁcation

Database

Selected articles

Google Scholar

Scielo

Elsevier

Total

Amsterdam

Classification

Description

Strasberg

Classification

Description

Type A

Minor bile leak affecting

peripheral ducts (cystic,

terminal ducts, or Luschka)

Type A

Inadvertent cut of the

cystic duct

Type B

Major bile leak affecting

main ducts (common bile

duct, common hepatic,

right or left hepatic), with

or without stricture

Type B

Inadvertent cut of the

cystic duct with injury

to the common hepatic

duct or common bile

duct

Type C

Bile duct stricture without

leak

Type C

Inadvertent cut of the

common

hepatic duct

or common bile duct

Type D

Duct section or resection,

with or without surgical

ligation or stapling.

Type D

Inadvertent cut of the

right or left bile duct

Classification of Biliary Leaks

Type E

Laceration of the

biliary tract.

Low-Grade

Biliary Leaks

Become evident after opacifying the intrahepatic biliary tree

High-Grade

Biliary Leaks

Are evident before opacifying the intrahepatic biliary tract.

Database

Articles found

Google Scholar

Scielo

Elsevier

Total

115

Source: Rojas & Vera (7).

Additionally, Rojas & Vera (7) highlight the

distinction between low-grade biliary leaks,

which become evident after opacifying the

intrahepatic biliary tree, and high-grade bi-

liary leaks, which are detected before per-

forming said opaciﬁcation. Both systems

provide detailed guidance for the classiﬁ-

cation and understanding of biliary compli-

cations, being valuable tools in the surgical

and medical ﬁeld.

It is important to explain that the pathologies

of the biliary tract described by Rojas & Vera

(7), citing Gonzales and Vergara, are one of

the most frequent diseases in the digestive

system and have been declared one of the

diseases that has affected a large popula-

tion worldwide. However, factors such as

age or obesity are important. Nevertheless,

among the complications associated with

biliary tract injuries, the Faculty of Medical

USE OF INDOCYANINE GREEN (ICG) FLUORESCENCE IN LAPAROSCOPIC SURGERY: BENEFITS IN ANA-

TOMICAL IDENTIFICATION AND PREVENTION OF BILIARY INJURIES. A SYSTEMATIC REVIEW

716

RECIMUNDO VOL. 9 N°2 (2025)

Sciences in Asunción in December 2021

describes bile leakage, jaundice caused by

obstruction, and hepatic ischemia after a

vascular injury.

Table 4. Dosage and administration time of ICG used in CL

Authors

Solution

Concentration

Number of Patients

Where Technique Was

Used

Results of Biliary Anatomy

Visualization in LC

Graves C, Sora

E, Idowu O

0.025 mg/ml

90.9% visualization rate of the

total length of the CBD

Nitta T, Kataoka

J, Ohta M

0.025 mg/mL

Successful and rapid detection of

the CC and CBD

Skrabec C, Pardo

F, Espin F

0.25 mg/mL

80% visualization rate of

Hartmann's pouch

Liu Y-Y, Liao C-

H, Diana M

0.125 mg/mL

77.8%* and 100% visualization

rates of the CC

Shibata H, Aoki

T, Koizumi T

0.025 mg/ml

100% visualization rates of CC,

CBD, and CHD in all 3 structures

Authors

Type of Study

Dose

Administration

Time Prior to CL

Dip F, Sarotto L, Stassen

L et al

Literature

Review

0.05 mg/kg - 2.5

45 to 60 minutes

Vlek S, van Dam D,

Rubinstein S et al

Systematic

Literature

Review

0.05 mg/kg - 2.5

45 to 60 minutes

Guillen G,

LópezFernández J,

Molino

Pilot Series

2.5 mg/kg

45 minutes

Palafox S

Thesis

2.5 to 10 mg

30 minutes to 2 hours

Ankersmit M, van Dam

D, van Rijswijk A-S

Case Study

0.2 mg/kg to 0.5

mg/kg

30 to 60 minutes

Zarrinpar A, Dutson E,

Mobley C

Prospective

Study

0.02 to 0.25

mg/kg

5 to 15 minutes, 45

minutes, 1 hour

Boogerd L, Handgraaf H,

Huurman V, Lam H-D

Systematic

Literature

Review

2.5 mg, 5 mg, 10

During the hour prior

to CL, 30 to 60 min,

24 hours

Boogerd L, Handgraaf H,

Huurman V, Lam H-D

Clinical Trial

5 mg, 10 mg

3 to 6 hours, 5 to 23

hours

Agnus V, Pesce A, Boni

Online Secured

Database

(EURO-FIGSb)

0.3 mg/kg

6 hours

Source: López & Velásquez (1).

Fluorescent Image-Guided Surgery

For ﬂuorescent image-guided surgery,

López & Velásquez (1) indicate that a so-

lution is prepared with a 25 mg vial of ICG

powder and dissolved in 10 ml of sterile

water, resulting in a 2.5 mg/ml dye solution.

Subsequently, 1 ml of the previously pre-

pared solution is dissolved in 9 ml of ste-

rile water to obtain a 0.25 mg/ml solution.

Intraoperatively, after preparation, a Kumar

cholangiography catheter is used, introdu-

ced through the umbilical port once the fun-

dus of the gallbladder is held and retracted.

Guided by a dissection instrument, the in-

fundibulum of the gallbladder is punctured

with the Kumar catheter, where 9 ml of bile

are aspirated through the needle that said

catheter possesses, which are then mixed

in a syringe with 1 ml of the ICG solution,

creating a 0.025 mg/ml ICG/bile solution.

This mixture, when reinjected into the gall-

bladder, immediately stains the structures,

spreading to the cystic duct and the rest of

the extrahepatic bile ducts. When the Ku-

mar catheter is removed, the puncture site

is obliterated with a Maryland clamp.

CHANCUSIG REINOSO, A. S., SOLIS VINUEZA, A., SALGADO CEDEÑO, J. D., & VILLAGÓMEZ ALBÁN, N. F.

717

RECIMUNDO VOL. 9 N°2 (2025)

Table 5. Results of the use of the intravesicular ICG injection technique

Source: López & Velásquez (1).

Authors

Solution

Concentration

Number of Patients

Where Technique Was

Used

Results of Biliary Anatomy

Visualization in LC

Graves C, Sora

E, Idowu O

0.025 mg/ml

90.9% visualization rate of the

total length of the CBD

Nitta T, Kataoka

J, Ohta M

0.025 mg/mL

Successful and rapid detection of

the CC and CBD

Skrabec C, Pardo

F, Espin F

0.25 mg/mL

80% visualization rate of

Hartmann's pouch

Liu Y-Y, Liao C-

H, Diana M

0.125 mg/mL

77.8%* and 100% visualization

rates of the CC

Shibata H, Aoki

T, Koizumi T

0.025 mg/ml

100% visualization rates of CC,

CBD, and CHD in all 3 structures

Authors

Type of Study

Dose

Administration

Time Prior to CL

Dip F, Sarotto L, Stassen

L et al

Literature

Review

0.05 mg/kg - 2.5

45 to 60 minutes

Vlek S, van Dam D,

Rubinstein S et al

Systematic

Literature

Review

0.05 mg/kg - 2.5

45 to 60 minutes

Guillen G,

LópezFernández J,

Molino

Pilot Series

2.5 mg/kg

45 minutes

Palafox S

Thesis

2.5 to 10 mg

30 minutes to 2 hours

Ankersmit M, van Dam

D, van Rijswijk A-S

Case Study

0.2 mg/kg to 0.5

mg/kg

30 to 60 minutes

Zarrinpar A, Dutson E,

Mobley C

Prospective

Study

0.02 to 0.25

mg/kg

5 to 15 minutes, 45

minutes, 1 hour

Boogerd L, Handgraaf H,

Huurman V, Lam H-D

Systematic

Literature

Review

2.5 mg, 5 mg, 10

During the hour prior

to CL, 30 to 60 min,

24 hours

Boogerd L, Handgraaf H,

Huurman V, Lam H-D

Clinical Trial

5 mg, 10 mg

3 to 6 hours, 5 to 23

hours

Agnus V, Pesce A, Boni

Online Secured

Database

(EURO-FIGSb)

0.3 mg/kg

6 hours

Applications in Laparoscopic Surgery

Regarding the application of laparoscopic

surgery, Farfán Feijoo et al (3) state that the

Mexican Social Security Institute distingui-

shes three types, which are explained be-

low: Exploratory laparoscopy and diagnos-

tic or therapeutic laparoscopy, and indicate:

1. Exploratory Laparoscopy: Surgical

opening of the abdomen, and review of

the abdominal and pelvic organs. It is

the exploration of the abdominal cavity

through optics introduced through oriﬁ-

ces in the abdomen and whose purpose

is the observation of the abdominal or-

gans, which is carried out through small

incisions through a needle that inﬂates

gas (CO2) and trocars; it can be Diag-

nostic or Therapeutic.

2. Diagnostic or Therapeutic Laparos-

copy: Laparoscopic technique or in-

tervention for the purpose of exploring

and studying organs and systems. In

this same vein, Morales Alfaro, Américo,

Quispe Rojas Wanda Thongshi, Velas-

quez Delgado Fredy and Fernandez Yu-

panqui Lenin (5), point out in their study

carried out circumscribed to "frequent

surgical pathology was gynecological,

biliary and appendicular."

3. Diagnostic Laparoscopy (LDx): It is a

modality of laparoscopy whose funda-

mental objective is to determine the pa-

thology causing a speciﬁc clinical pic-

ture, in which a precise diagnosis could

not be reached. This can be therapeutic

in many cases, those in which it is fea-

sible by laparoscopic surgery and in

which the surgeon is trained to perform

it. The techniques followed are the same

as standard abdominal or thoracic lapa-

roscopy. Exploratory Laparotomy (EL):

Any laparotomy used with the purpose

of reaching a diagnosis that could not be

determined through the clinical picture

and complementary examinations.

According to Farfán Feijoo et al (3), it can

have utilities for exploratory laparotomy and

diagnostic laparoscopy because it exami-

nes organs and structures, so its beneﬁts

are stated, indicating the following:

1. Acute abdominal pain.

2. Staging of oncological pathology.

3. Release of adhesions.

4. Ablation of endometriosis.

5. Aspiration of ovarian cysts.

6. Chronic pelvic pain.

7. Dysmenorrhea in adolescents.

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8. Diagnosis and follow-up of endometriosis.

9. Second Look: Reintervention for cancer

for prognosis and treatment.

10. The authors mentioned above in the in-

vestigative work called.

According to Farfán Feijoo et al (3) indicates

that the main reason for choosing the explo-

ratory laparotomy (EL) technique is acute ab-

domen, unlike diagnostic laparoscopy (DL)

whose main reason for choice is to determine

the cause of infertility; this may be an indica-

tion of the limited knowledge of the wide utili-

ty offered by DL, as well as a consequence of

it still being a developing technique.

1. The diagnostic results with both techni-

ques do not have signiﬁcant variation, so

they can be alternatively replaced.

2. The minimum percentage of postoperati-

ve complications occurs in DL.

3. The maximum average length of hospital

stay occurs in EL.

4. The analysis of the operation performed

in relation to the diagnosis demonstrates

a similar utility of DL and EL for making

diagnoses, although the therapeutic uti-

lity for deﬁnitive cure is surpassed in EL.

5. The operative time of LDx is less than that

established in EL, which decreases expo-

sure to damage from surgical trauma.

6. In accordance with previous studies,

the advantages of smaller incision size

are conﬁrmed in the lesser need for use

in number, time, and intensity of analge-

sic drugs.

7. DL is a simple, safe, and inexpensive

procedure; the morbidity and mortality of

the procedure are low when performed

with appropriate indications and by tra-

ined personnel.

8. DL has increased signiﬁcantly in both

emergency and hospitalization surgical

services, due to the deﬁnitive advantages

that this method has and that translates

into a decrease in the cost-beneﬁt ratio

for both the patient and our institutions.

It is important to highlight that laparoscopy

for Farfán Feijoo et al (3) has diverse uses

explaining the following: In general, its com-

mon use is to detect a medical problem

such as chronic pelvic pain (pain lasting

more than six months), and also, to carry out

a series of minor and complex operations or

surgeries carried out with the help of a ca-

mera with a few small incisions mainly in the

abdomen or pelvis. With laparoscopy, a con-

dition can also be diagnosed. In this case,

the procedure is called diagnostic laparos-

copy. Tissue samples can also be obtained

for medical examinations and tests. Throu-

gh this technique, practically any abdomi-

nal and pelvic surgery can be performed,

among some of them are appendectomies,

cholecystectomies, cystectomies, pancrea-

tectomies, intestinal resections, and sur-

gical sterilizations, and all of these can be

done using the umbilicus as an entry point

for the trocar. In gynecological matters, for

example: cystectomies, hysterectomies, en-

dometriosis cauterization, myomectomies,

release of adhesions, infertility, tubal liga-

tions, etc.

Benets of Laparoscopic Surgery

Minimally Invasive Surgery (MIS) techniques

or procedures, according to Farfán Feijoo et

al (3), present several advantages, espe-

cially for the patient and healthcare entities,

which has led to a wide interest in recent

years in the utilization and advancement of

such techniques in different ﬁelds of sur-

gery, such as: abdominal surgery, cardiac

surgery, traumatology, neurosurgery, and

orthopedics, etc. Among the advantages

presented by the literature regarding open

surgery, the minimally invasive laparoscopic

surgical technique presents several advan-

tages, among them:

1. Faster recovery improving early mobi-

lization, general and emotional state of

the patient.

CHANCUSIG REINOSO, A. S., SOLIS VINUEZA, A., SALGADO CEDEÑO, J. D., & VILLAGÓMEZ ALBÁN, N. F.

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RECIMUNDO VOL. 9 N°2 (2025)

2. Hospital stay decreases due to faster re-

covery.

3. Postoperative pain is much less and,

consequently, the intake of analgesics is

reduced as the patient feels well.

4. Smaller wounds.

5. Less bleeding.

6. More precise sutures.

7. Less tissue separation to access the

area to be treated.

8. Faster return to normal activity.

9. The patient's work leave time is shorter.

10. Results similar or superior to open surgery.

11. Reduction of intervention costs.

12. Hardly leaves a scar. The three or four in-

cisions become almost invisible over time.

13. The possibility of wound complications

such as: infection or eventrations, her-

nias in the operative wound, are reduced

to very low percentages.

The lesser manipulation of tissues and in-

testine when performed with ﬁner forceps,

means that the risk of adhesions between

tissues decreases and that the intestine re-

covers its mobility sooner, so food intake be-

gins earlier.

However, laparoscopic surgery presents

a series of disadvantages for the surgeon.

This is explained by Farfán Feijoo et al (3),

where each of them is indicated and it is

considered that they should be taken into

account in order to avoid situations that

affect the health of patients:

Restricted vision of the operative ﬁeld as

it is performed through a mini-camera that

sends the signal to a monitor.

• Restricted mobility of surgical instru-

ments.

• Difﬁculty in handling instruments.

• Magniﬁcation of the surgeon's move-

ments, such as tremors, etc.

• Among the physiological and pathologi-

cal ones are:

• An exaggerated pneumoperitoneum can

compress the diaphragm and the base

of the lungs, leading to postoperative

hypoxemia.

• Previous adhesions can prevent obtai-

ning a pneumoperitoneum.

• There is a risk of gas embolism, although

it is very rare.

• Tactile information is lost, which is impor-

tant in the evaluation of some localized

disorders. That is, null tactile perception

for the surgeon with the exception of for-

ce feedback.

• Precise control of bleeding is more difﬁ-

cult.

Applications in Laparoscopic Surgery:

Biliary Mapping

Laparoscopic biliary mapping surgery, ac-

cording to Garnica (13), states that Dr. Ngu-

yen coined the term "strategic laparoscopic

surgery," deﬁning it as laparoscopic surgery

where aesthetic results are improved com-

pared to the conventional technique, but

maintaining the same level of safety and

feasibility of the latter. Kuroki was one of the

pioneers in describing the reduced-port la-

paroscopic cholecystectomy technique in

2011, and since then, multiple modiﬁcations

have been made to it, each with different

advantages and disadvantages.

Regarding the TILC technique, Garnica

(13), citing Abaid, Cecconello, and Zilbers-

tein, states that it is a procedure which can

be performed with the same instrumentation

and experience of a surgical team trained

in CLC, making the pertinent changes men-

tioned above. Although two ports are pla-

ced in a single incision, the most important

foundation of laparoscopic surgery, which

is the principle of triangulation, is not infrin-

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ged. Once the steps of the technique are

followed, the rest of the procedure is indiffe-

rent to the conventional one, even allowing

in most cases for a good critical safety view.

However, the most important technical di-

sadvantage is perhaps the collision of the

forceps in the umbilical trocars. In expe-

rience, this can be avoided by positioning

the optic on as vertical an axis as possible

(taking advantage of being 30°) and not ge-

tting too close to the operative ﬁeld when

the main surgeon is using the third trocar's

forceps; once the forceps have been secu-

red at a point where they do not need to be

mobilized, the cameraman can approach

without problems. Another way to avoid

this problem is the correct placement of the

trocars at the beginning of the surgery: wi-

thin the same umbilical incision, the further

apart the introduction oriﬁces of both trocars

are and the more they are placed on a di-

fferent rotational axis (creating a kind of "X"

between them), the lower the probability of

inter-instrument collision.

For Garnica (13), the greatest advantage

provided by the TILC technique is regarding

the cosmetic result and postoperative pain.

The data from the present study reveal that

pain is signiﬁcantly less when quantiﬁed at

24 hours’ post-surgery following the already

mentioned instrument. This may be related to

the reduction in the number of skin incisions

made in this procedure, unlike the conven-

tional method. Regarding the aesthetic out-

come, it is directly related to the reduction in

the number of scars on the abdominal wall,

since the TILC technique uses 2 trocars in a

single incision that corresponds to the umbi-

lical scar, almost imperceptible. The other im-

portant point to highlight is that this surgical

procedure is performed in a similar operative

time and with a similar complication rate to

the conventional technique, being statistica-

lly non-signiﬁcant, so it is considered safe

and effective, without emphasizing that the-

re is no need to use different instruments or

have a speciﬁc learning curve, so the costs

of the surgery are practically identical.

Likewise, Garnica (13) mentions cases

where the surgery had to be converted; in

the TILC group, there was a need to place

an extra trocar in a patient with a history

of cholangitis and endoscopic instrumen-

tation of the biliary tract, since among the

intraoperative ﬁndings, a partially intrahe-

patic thick-walled gallbladder stood out,

whose mobilization was not feasible using

only the method of fundal retraction with the

trans-parietal needle. In the consulted lite-

rature, it is evident that the conversion ra-

tes for this procedure are 3-5% in difﬁcult

cases, making the clariﬁcation that the term

"conversion" in this context is not synony-

mous with open surgery, but rather refers to

the act of placing one or two extra trocars to

facilitate the surgical procedure.

Laparoscopic cholecystectomy, according

to Garnica (13), has revolutionized gallbla-

dder surgery since its introduction in 1985,

becoming the gold standard for the treat-

ment of symptomatic gallstone disease.

This procedure has proven to be superior

to traditional open surgery in terms of aes-

thetic results, less postoperative pain, and

faster recovery, allowing patients to return

to their daily activities in less time. Over the

years, the laparoscopic technique has been

reﬁned and expanded to include a variety

of indications, from cholelithiasis to acu-

te cholecystitis and gallstone pancreatitis.

However, it is crucial to consider contraindi-

cations and carefully evaluate patients with

signiﬁcant comorbidities, as general anes-

thesia and pneumoperitoneum can increase

risks in certain groups.

For Garnica (13), the success of laparosco-

pic cholecystectomy also depends on the

surgeon's skill and experience, especially

in complicated cases such as acute chole-

cystitis or the presence of adhesions. Preci-

se identiﬁcation of anatomy and the appli-

cation of safe techniques, such as critical

view of safety, are fundamental to minimize

intraoperative and postoperative complica-

tions. In summary, laparoscopic cholecys-

tectomy has not only improved surgical out-

CHANCUSIG REINOSO, A. S., SOLIS VINUEZA, A., SALGADO CEDEÑO, J. D., & VILLAGÓMEZ ALBÁN, N. F.

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RECIMUNDO VOL. 9 N°2 (2025)

comes and patient quality of life but has also

established a new paradigm in minimally

access surgery. As technology and techni-

ques continue to advance, this procedure is

likely to remain a cornerstone in abdominal

surgery, beneﬁting an increasing number of

patients worldwide.

Evaluation of the Biliary Tree

The evaluation of the biliary tree, according to

Haggerty et al (14), can be performed using

intraoperative cholangiography or laparosco-

pic ultrasound to assess the biliary tree. This

allows for evaluating biliary anatomy (duct

size, integrity, anatomical variations, pre-

sence of stones) and characterizing stones

(location, size, number). Ultimately, it helps

the surgeon decide the optimal approach for

common bile duct exploration (transcystic or

transcholedochal). These two forms of eva-

luation are explained below:

1. Intraoperative Cholangiography (IOC)

Although an IOC can be performed with

plain radiography, dynamic ﬂuoroscopy is

strongly recommended given its usefulness

in exploring the common bile duct. Studies

also suggest that it can be more efﬁcient

and accurate.

• The IOC must be carefully inspected to

evaluate the entire biliary tree. Speciﬁcally:

• Cystic duct: length, tortuosity, caliber, in-

sertion point into the cystic duct.

• Common bile duct: caliber, leak, obs-

truction, ﬁlling defects (stones vs. air),

contrast ﬂow into the duodenum.

• Common, right, and left hepatic ducts:

caliber, leak, obstruction, ﬁlling defects

(stones vs. air), visualization of bifurca-

tion, aberrant sectional right duct ana-

tomy (14).

Nevertheless, according to Haggerty et al

(14), it is important to identify the right ductal

anatomy during IOC due to the variability of

the sectional ducts. The right anterior sec-

tional duct (segments 5 and 8) and the right

posterior sectional duct (segments 6 and 7)

must be identiﬁed separately. Speciﬁcally,

the right posterior sectional duct must be

clearly deﬁned, as its entry into the central

biliary tree is variable and it can insert below

the bifurcation, into the cystic duct, into the

gallbladder, or into the left main bile duct, in

addition to being vulnerable to injury during

cholecystectomy. The failure to identify the

right ductal structures should alert to abe-

rrant anatomy or possible biliary injury. If the

presence of stones is suspected when the

IOC shows a radiolucent defect, a menis-

cus, biliary tree dilation, or inability of con-

trast to enter the duodenum.

Similarly, Haggerty et al (14) indicate that la-

paroscopic common bile duct exploration is

an established procedure that offers the po-

tential to provide single-stage management

for patients with choledocholithiasis. It pre-

sents a safety proﬁle comparable to ERCP

with laparoscopic cholecystectomy, in addi-

tion to offering lower costs and shorter hos-

pital stays. Transcystic common bile duct

ultrasound (TCBDUS) is a safe procedure,

accessible to most general surgeons who

frequently perform cholecystectomies. Whi-

le transcystic common bile duct ultrasound

(TCBDUS) offers greater efﬁcacy for stone

removal and access to the entire biliary tree,

it is associated with higher complication ra-

tes compared to transcystic exploration and

requires more advanced skills.

2. Laparoscopic Ultrasound

Laparoscopic ultrasound, according to Ha-

ggerty et al (14), explains that laparosco-

pic ultrasound can be performed instead of

IOC to determine biliary anatomy, including

duct size, stone characteristics, and ampu-

llary and pancreatic head abnormalities that

may affect the procedure. The conﬂuence of

the right and left hepatic ducts can be ob-

served, as well as the junction of the cystic

duct with the common bile duct. The com-

mon bile duct is followed to the duodenum

to evaluate choledocholithiasis.

USE OF INDOCYANINE GREEN (ICG) FLUORESCENCE IN LAPAROSCOPIC SURGERY: BENEFITS IN ANA-

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Beneﬁts in Anatomical Identiﬁcation Throu-

gh the Use of Fluorescence and Prevention

of Biliary Injuries in Laparoscopic Surgery

Among the beneﬁts in anatomical identiﬁ-

cation through the use of ﬂuorescence, as

pointed out by López & Velásquez (1), ICG

is a tricarbocyanine dye, characterized by

being a green lyophilized powder, soluble

in water. Some of the most important pro-

perties of this substance are that it is not

pharmacologically active, not toxic, has no

known metabolites, and the risk of adminis-

tering this medication is minimal, as few ad-

verse reactions have been reported.

However, Ankersmit et al; Baladrón Gonzá-

lez (15,16) explain that this substance, upon

intravenous injection, immediately binds to

plasma proteins (albumin), so it remains

within the vasculature throughout its circu-

lation. It has exclusively hepatic excretion

through bile, avoiding enterohepatic recir-

culation. The elimination process is throu-

gh passive uptake (concentration gradient)

from the blood into the hepatocytes, which

actively eliminate it into the bile canaliculi.

The clearance rate, as mentioned by López

& Velásquez (1) citing Reinhart, Huntington,

Blair, Heniford, and others, indicates that ICG

is 18 to 24% per minute in the liver. The dye

is cleared from the body exponentially in the

ﬁrst 20 minutes after its application, with a

half-life of 3 to 4 minutes. After this period,

the clearance rate decreases, and the com-

pound remains in the plasma for more than

an hour. The elimination rate of the dye is di-

rectly proportional to its concentration. These

characteristics allow for multiple injections of

the compound during the same procedure.

In relation to ﬂuorescent cholangiography

with indocyanine green, López & Velás-

quez (1) point out that it reports advantages

over rescue surgical techniques and over

intraoperative methods such as traditional

intraoperative cholangiography, such as re-

duced costs and personnel needed, absen-

ce of radiation exposure, reduced surgical

time, and technical facilities that allow multi-

ple applications during the same procedure,

becoming an ideal method in the prevention

of iatrogenic biliary tract injuries.

Conclusions

It can be concluded that the administration

of indocyanine green (ICG) ﬂuorescence in

laparoscopic surgery is of great utility, being

an efﬁcient method that helps in the precise

real-time visualization of anatomical structu-

res of the bile ducts, cystic duct, and blood

vessels, allowing to reduce the probability of

accidental injuries in the biliary tree and other

surrounding tissues. Within the surgical pro-

cess, it allows the surgeon to perform dissec-

tion precisely and avoid iatrogenic injuries,

due to the identiﬁcation of anatomical structu-

res, preventing complications during surgery.

Regarding the beneﬁts of using indocyanine

green (ICG) ﬂuorescence in laparoscopic

surgery for the prevention of biliary injuries, it

is characterized by being a safe technique,

because structures are identiﬁed through

a laparoscopic camera, where biliary ana-

tomy can be precisely observed, minimizing

the probability of errors during the surgical

intervention. Another advantage of this type

of surgical procedure is that, as it is a mini-

mally invasive procedure, the patient reco-

vers more quickly, because they experience

less pain and the probability of infections is

reduced. Even ICG is a useful tool for senti-

nel lymph node mapping, allowing the iden-

tiﬁcation of metastases.

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TOMICAL IDENTIFICATION AND PREVENTION OF BILIARY INJURIES. A SYSTEMATIC REVIEW

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gómez Albán, N. F. (2025). Use of indocyanine green (ICG) ﬂuorescence in

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