The Role of Indocyanine Green Navigation in Choledochal Cyst Surgery

Choledochal cysts (CDCs) are rare congenital entities characterized by biliary tract dilatation that predisposes to the development of malignant tumors, mainly cholangiocarcinoma, so even if it is asymptomatic, CDC should be excised at the time of the diagnosis. Complete cyst excision is the main factor involved in decreasing the risk of malignancy. However, accurate definition of the cyst extension is often challenging, mainly in fusiform types such as type I in Todani’s classification. For this reason, correct intraoperative identification of CDC limits as well as intrahepatic and intrapancreatic biliary structures is essential. Here, we present the utility of indocyanine green (ICG) navigation during CDC surgery. A 18-month-old girl being followed up for a fusiform CDC type Ic according to Todani’s classification presented progressive growth on MRI of 14.5 mm in diameter. Elective surgery with ICG-guided near-infrared (NIR) fluorescence was performed. Preoperative intravenous ICG (0.5 mg/kg) was injected 8 h before surgery. Detailed anatomical mapping of extrahepatic biliary structures was performed using RUBINA™ system, which also allowed the delineation of the intrahepatic extension of the CDC. The intra-pancreatic part of the CDC was identified and dissected. After identification of the main hepatic ducts by ICG-navigation, the CDC was completely resected and finally, reconstruction by Roux-en-Y hepaticojejunostomy was performed. ICG navigation in NIR mode helps to delineate biliary anatomy and allows intraoperative detection of any leak of the hepatic-jejunal anastomosis, and therefore, its use should be encouraged in these types of interventions.