Impact of Indocyanine Green in Laparoscopic Cholecystectomy: Enhancing Safety, Reducing Conversion Rates and Optimizing Operative Time through Predictive Scoring Systems

Impact of Indocyanine Green in Laparoscopic Cholecystectomy: Enhancing Safety, Reducing Conversion Rates and Optimizing Operative Time through Predictive Scoring Systems | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Indocyanine Green in Laparoscopic Cholecystectomy: Enhancing Safety, Reducing Conversion Rates and Optimizing Operative Time through Predictive Scoring Systems Natalia Pujol-Cano, José Miguel Morón-Canis, Elías Palma-Zamora, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6900172/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Jan, 2026 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted 16 You are reading this latest preprint version Abstract Background Laparoscopic cholecystectomy(LC) is the standard treatment for gallbladder disease. However, complex cases may require conversion to open surgery. Indocyanine green near-infrared fluorescence cholangiography(ICG NIRF-C) enhances biliary visualization, potentially reducing conversion rates, surgical time and complications.This study evaluates ICG’s role in improving LC outcomes using five predictive risk scores. Study Design Forty-four LC patients received a single 0.25 mg intravenous ICG dose during anesthesia induction. Data collected included demographics, biliary visualization before and after dissection, complications, operative time and risk scores. Results ICG fluorescence improved biliary visualization: common bile duct(CBD) was identified in 29% of cases before and 100% after dissection. Despite 61.4% of patients having a CLOC score > 6 and 43.2% a G10 score ≥ 3 no conversions occurred. Only 7% of cases exceeded 90 minutes (p = 0.03). Conclusion ICG NIRF-C enhances biliary anatomy visualization, reducing conversion rates and operative time, supporting its integration as a standard LC tool. Introduction Since its introduction in the late 1980s, laparoscopic cholecystectomy (LC) has become the gold standard for treating gallbladder disease 1–6 . This minimally invasive technique offers numerous advantages, such as faster recovery, reduced postoperative pain, and shorter hospital stays 1,7–9 . Additionally, ambulatory LC has gained recognition as a safe and effective procedure, enabling faster recovery in a home setting 8,9 . However, conversion to open surgery remains a challenging necessity in certain cases due to severe inflammation, anatomical variations, or extensive adhesions. These factors increase the difficulty of identifying biliary anatomy, leading to higher morbidity, longer hospitalizations, and significantly increased costs 2,4,7,9 . Notably, the primary cause of bile duct injury (BDI) in up to 97% of cases is misinterpretation of biliary structures 5,6 . In this context, contrast agents such as indocyanine green (ICG) have emerged as promising tools to enhance intraoperative visualization of the biliary tree, potentially reducing complications, shortening surgical times, and preventing conversions to open surgery 10–12 . In this study, we aimed to evaluate the impact of indocyanine green near-infrared fluorescence cholangiography (ICG NIRF-C) in laparoscopic cholecystectomy (LC), particularly in high-risk cases, by analyzing its effect on biliary structure visualization, conversion to open surgery, operative time, and potential implications for ambulatory surgery. To support these claims, we examine five predictive scoring systems: CLOC, G10, CAAD, the Nassar Score (2019), and the Surgical Time Score (CholeS Study Group). Material and methods Trial design and patients This was a descriptive study. Ethical clearance for the study was granted by the institutional review board, designated as CI-344-19. Patients underwent surgery between January 2019 and January 2020. All surgeries were performed by the same surgical team, thus neutralizing any bias with respect to observation of the biliary anatomy while using ICG NIRF-C. Those patients with a prior history of symptomatic cholelithiasis such as biliary colic, acute or chronic cholecystitis, choledocholithiasis, pancreatitis or gallbladder polyps were enrolled in the study to undergo LC with NIR-ICG fluorescence imaging. Other inclusion criteria were age ≥ 18 years old, normal liver and kidney function, no allergies to ICG or iodine, ability to understand and follow study procedures and having provided signed consent. The exclusion criteria were age < 18 years old, liver or kidney dysfunction, known history of cholangitis or prior common bile duct injury, allergy to ICG or iodine, pregnancy or breast-feeding and inability to understand and follow study procedures. None of the patients was taking medication interfering with hepatic ICG uptake. The patient withdrawal criteria were withdrawal of informed consent or lost to follow-up. Patient data were collected at enrolment, during surgery, immediately after surgery and up to 90 days postoperatively. Outcomes measures The data recorded included age, gender, diabetes mellitus, hypertension, dyslipidaemia, body mass index (BMI), American Society of Anaesthesiologists (ASA) physical status classification, surgical indication, intraoperative complications, hepatic hyperluminescence, visualization of biliary structures such as the cystic duct (CD), the common bile duct (CBD) and the cystic duct–bile duct junction (CDBDJ) before and after dissection of Calot’s triangle, conversion to open surgery, postoperative complications graded according to the Clavien–Dindo classification 24 , BDI described according to Strasberg classification 25 , hospital stay and readmission. In our study, we have also used the Nassar classification 17 to perform a visual intraoperative assessment of the surgical difficulty at the beginning of each cholecystectomy given that it is easy to use and reproducible and reflects the tendency to suffer from BDIs as well as prolonged surgical times and conversion to open surgery. The Nassar scale grades operative findings 17 from the gallbladder, cystic pedicle and associated adhesions. In grade 1, the gallbladder is floppy and non-adherent, the cystic pedicle is thin and clear, and the adhesions are simple up to the neck/Hartmann’s pouch. In grade 2, the gallbladder can be packed with stones, the cystic pedicle is fat laden, and adhesions are simple up to the body. In grade 3, the gallbladder can have a deep fossa, acute cholecystitis and fibrosis, and Hartmann’s pouch is adherent/impacted to CBD. The cystic pedicle can have abnormal anatomy, or the cystic duct is short, dilated or obscured. Adhesions are dense up to the fundus or involving hepatic flexure or duodenum. In grade 4, the gallbladder is completely obscured or can have empyema or gangrene. The cystic pedicle is impossible to clarify, and adhesions are dense with fibrosis, wrapping the gallbladder. The duodenum and/or hepatic flexure are difficult to separate. On the other hand, when we analyse the variable “gallbladder inflammation”, it corresponds to the pathological anatomy of the surgical specimen and is classified as absence of inflammation, acute inflammation, or chronic inflammation. Surgical and fluorescence cholangiography techniques ICG is a fluorophore that, when administered intravenously, binds to plasma proteins and is primarily eliminated by the liver enhancing the perception of biliary anatomy 10–28 . A unique dose of 0.25 mg of ICG dye was administered intravenously 15 min before the surgery during the anaesthesia induction. After placing ports, the scope was introduced into the abdominal cavity. We then exposed the gallbladder in order to visualize Calot’s triangle and recorded the exact moment when Calot’s triangle first became visible by ICG NIRF-C imaging before performing dissection. We confirmed the absence of aberrant bile ducts and then bluntly dissected Calot’s triangle after achieving the “critical view of safety” described by Strasberg and isolating the cystic duct and cystic artery with ICG NIRF-C in overlay mode. The cystic duct and cystic artery were clipped and divided after confirming the CDBDJ using fluorescence cholangiography. We then dissected the gallbladder from the liver bed. Upon completion of all laparoscopic procedures, we performed NIRF-C again to examine the cystic duct stump and confirm the absence of any bile leakage. Finally, the gallbladder was removed from the abdomen using a retrieval bag. Laparoscopic equipment We used the VISERA ELITE II Surgical Endoscope System (Olympus Corporation, Shinjuku, Tokyo, Japan) for NIR/ ICG imaging with a 30° forward oblique laparoscope. NIR images were obtained by combining an infrared light source and infrared telescope with the video system centre, camera head and monitor used for white light (WL) images. Images can be switched between WL and NIR light by pushing a button conveniently located on the camera head. The OTV-S300 video system centre uses an LED light source instead of a xenon lamp. During LC, alternating exposure to WL to NIR light sources can be used to identify biliary structures before, during and after dissection. In overlay mode, the regular WL image is combined with the NIR/ICG data to generate an overlay image. In our study, we performed all surgeries in overlay mode in order to identify each ICG stained biliary structure while dissecting Calot’s triangle. Predictive Scoring Systems We have also investigated the relationship between ICG NIRF-C during LC and five surgical risk assessment systems: CLOC 27 , G10 26 , Nassar Score (2019) 30 , CAAD 28 and the Surgical Time Score 29 (from the CholeS Study Group). These scoring systems were chosen because they provide valuable insights into key surgical challenges, such as predicting conversion to open surgery, assessing surgical complexity, and estimating operative time. The CLOC score is a validated preoperative risk assessment tool designed to predict the likelihood of conversion from laparoscopic to open cholecystectomy 27 . As described in this study, we have also stratified patients as higher risk of conversion if they had a CLOC score > 6 27 . The G10 score is an intraoperative gallbladder scoring system prospectively evaluated to predict surgical outcomes, particularly the feasibility of completing the operation laparoscopically 26 . This scoring system was developed in a multicenter study led by the World Society of Emergency Surgery 26 . Gallbladder surgery was considered easy if the G10 score < 2, moderate (2 ≦ 4), difficult (5 ≦ 7) and extreme (8 ≦ 10) 26 . The optimal cut-off point of 0.067 (score of 3) was identified in G10 and conversion to open cholecystectomy occurred in 33% of patients with G10 scores of ≥ 5 26 . We categorized our patients at higher risk of conversion to open surgery with G10 scores meeting the following thresholds: G10 ≥ 3 (moderate or higher difficulty) and G10 ≥ 5 (difficult or extreme cases). The Nassar scoring system (2019) is a predictive tool for assessing surgical difficulty in laparoscopic cholecystectomy and estimating the likelihood of conversion to open surgery based on operative findings 30 . It classifies cases into three risk levels—low (0–2 points), intermediate (3–4 points), and high (≥ 5 points)—to help anticipate surgical complexity, prolonged operative times, and potential complications 30 . In our study, patients were stratified accordingly into these three categories. The CAAD score is a validated system for predicting the success of day-case cholecystectomy operations) 28 . It was developed using data from a prospectively collected dataset of cholecystectomy patients from 166 UK and Irish hospitals (CholeS study)) 28 . This score is based on 10 preoperative factors, including patient demographics (age and gender), comorbidities (ASA score), history of previous hospital admissions for gallstone-related disease, primary indication for surgery (such as biliary colic, cholecystitis, or choledocholithiasis), preoperative imaging findings (thickened gallbladder wall or dilated common bile duct), and the type of preoperative investigations performed (radiological or endoscopic) 28 . Patients were identified as having a greater risk of unsuccessful day-case cholecystectomy if their CAAD score > 5 28 . By incorporating these variables, the CAAD score provides an objective tool for preoperative patient selection, optimizing surgical planning and resource allocation. Finally, the Surgical Time Score was developed to predict whether a surgery will exceed 90 minutes , helping to optimize operating room scheduling 29 . This score is based on 10 preoperative factors and categorizes patients into low (0–3 points), intermediate (4–7 points), or high risk (8 points or more) for prolonged operative time 29 . It has been validated and shown to improve efficiency in surgical planning 29 . In our study, the surgical times were also divided into three categories: less than 45 minutes, between 45 and 90 minutes, and more than 90 minutes. Statistical analysis Normality tests and graphs were used to determine whether variables followed a normal distribution. Data are presented as mean ± standard deviation (SD) for continuous variables, and those a non-normal distribution are expressed as median values and interquartile ranges. We used Student’s t test or the Wilcoxon test for paired samples for the quantitative variables. The Chi-square test and McNemar’s test were used for qualitative variables. Pearson’s correlation coefficient was used to determine the linear dependence between two quantitative variables. ANOVA test was used to compare continuous variable means of two or more groups. Linear regression analysis was also performed to assess the association of continuous variables. A p value of less than 0.05 was considered statistically significant. Statistical analyses were carried out with SPSS software 23.0 (SPSS Inc., Chicago, IL, USA). Results Forty-four patients (16 females (36%) and 28 males (64%)) were eligible for elective LC and included in our study. The mean age was 57±15 years. According to ASA score, 9 patients (20%) were ASA I, 24 (55%) were ASA II, and 11 (25%) were ASA III. Their mean BMI was 28 ± 5 kg/m2. The mean operation time was 45±15 min. The indications for surgery were 13 cases of symptomatic cholelithiasis (30%), 7 of choledocholithiasis (treated with preoperative endoscopic retrograde cholangiopancreatography) (16%), 12 of previous cholecystitis (27%) and 12 of lithiasic pancreatitis (27%). Twenty patients (45%) did not have gallbladder inflammation, 22 (50%) had chronic inflammation, and only 2 (5%) had acute inflammation. When classifying patients according to their Nassar grade, 20 (45%) were grade 1, 13 (29%) were grade 2, 8 (18%) were grade 3, and only 3 patients (7%) were grade 4. ICG NIRF-C was performed during LC in all 44 cases. No allergic reactions to ICG were reported. There were no BDIs and no conversions to laparotomy. The postoperative course was free of complications in all cases. The mean postoperative hospital stay was 28±4 h. No hospital readmissions were recorded. All other patient characteristics, intraoperative data and postoperative outcomes are reported in Table 1. Ability of fluorescence cholangiography to delineate the bile duct anatomy The CD or the CDBDJ could not be identified via fluorescence cholangiography in any of the patients before dissection of Calot’s triangle, whereas the CBD was detected using ICG NIRF-C in 13 patients (29%) before dissection of Calot’s triangle (Table 2). After dissecting Calot’s triangle (at average time of 25 min after starting surgery), ICG NIRF-C identified the CD and the CDBDJ in 31 (71%) and 37 (84%) patients, respectively. The CBD was detected in all 44 patients with ICG NIRF-C after dissection of Calot’s triangles. Statistically significant differences in the identification of the three bile structures using ICG NIRF-C were found before and after the dissection of Calot’s triangle (Table 2). No accessory bile ducts were identified in any of the LC interventions during ICG NIRF-C. No hepatic hyperluminescence was observed in any of the patients at an ICG dose of 0.25 mg. Clinical factors affecting the ability of fluorescence cholangiography to delineate the bile duct anatomy Table 3 summarizes the effects of clinical factors such as obesity and the degree of inflammation on the ability of ICG NIRF-C to delineate bile duct anatomy before and after dissecting Calot’s triangle. We observed statistically significant differences in the visualization of the CBD using ICG NIRF-C before dissecting Calot’s triangle in patients with a Nassar grade < 3 ( p = 0.013) and no gallbladder inflammation ( p = 0.001). In this manner, ICG NIRF-C could detect the CBD in 13 patients (39%) with a Nassar grade < 3 before dissection of Calot’s triangle and in 20 patients (65%) without gallbladder inflammation. There were no differences with respect to these clinical factors in the visualization of the rest of the biliary structures when using ICG NIRF-C before and after dissection of Calot’s triangle except for the post- dissection visualization of the CDBDJ in patients with no gallbladder inflammation ( p = 0.008) (Table 3). Relationship between CLOC, G10, CAAD, Nassar 2019 Scores and and Surgical Time Score (CholeS Study Group) and the Duration of Surgery Table 4 summarizes the relationship between CLOC, G10, CAAD and Nassar 2019 Scores and surgical times. Statistically significant differences were only observed in patients with G10 score ≥ 3 (p = 0.01) and G10 score ≥ 5 (p = 0.03). In this manner, 14 patients (56%) with G10 < 3 had a surgical time <45 min; 11 (44%) had a surgical time between 45 - 90 min and none of the patients with G10 90 min. Four patients (21%) with G10 ≥ 3 had a surgical time 90 min. On the other hand, 17 patients (47%) with G10 < 5 had a surgical time 90 min. One patient (12.5%) with G10 ≥ 5 had a surgical time 90 min. In our study, there were only 3 patients with a surgical intervention lasting more than 90 minutes, which corresponded to an intermediate score according to the Surgical Time Score (CholeS Study Group). Relationship between the ability of fluorescence cholangiography to delineate the bile duct anatomy before and after dissection of Calot’s triangle and CLOC, G10, CAAD, Nassar 2019 Risk Scores and Surgical Time Score (CholeS Study Group) Twenty-seven patients (61,4%) had a CLOC score > 6, 19 patients (43,2%) had G10 score ≥ 3, 8 patients (18,2%) had G10 score ≥ 5 and 28 (63,6%) had a CAAD score > 5. Regarding surgical Time Score (CholeS Study Group), nine patients (20.4%) had a low score, 32 (72.7%) had a intermediate score and 3 (6.8%) had a high score. Finally, eleven patients (25%) had a low Nassar Score 2019, 13 (29.5%) had a intermediate score and 20 (45.5%) had a high score. The mean, median, mode and standard deviation of CLOC score were 7.4, 7, 7 and +/-2.7; respectively. G10 score’s mean, median, mode and standard deviation were 2.6, 2, 1 and +/-1.6; respectively. The mean, median, mode and standard deviation of CAAD score were 6.4, 6, 6, +/-2.8, respectively. Mean, median, mode and standard deviation of Nassar score (2019) were 4.3, 4, 3 and +/-2.4; respectively. Finally, Surgical Time Score’s mean, median, mode and standard deviation were 4.5, 4.25, 3.5 and +/-1.8; respectively. Table 5 shows the relationship between the ability of ICG NIRF-C to delineate bile duct anatomy before and after dissecting Calot’s triangle and the mentioned scores. We observed statistically significant differences in the visualization of the CBD using ICG NIRF-C before dissecting Calot’s triangle in patients with G10 ≥ 3 ( p = 0.002), G10 ≥ 5 ( p = 0.043) and Nassar score 2019. Thus, ICG NIRF-C could detect the CBD in 12 patients (48%) with a G10 < 3 before dissection of Calot’s triangle and in only 1 patient (5.3%) with a G10 ≥ 3. Similary, ICG NIRF-C could detect the CBD in 13 patients (36%) with a G10 < 5 before dissection of Calot’s triangle and in none of the patients with a G10 ≥ 5. Regarding Nassar score 2019, ICG NIRF-C could detect the CBD before dissection of Calot’s triangle in 7 patients with low score (63.6%), 1 patient with intermediate score (7.7%) and 5 patients with high score (25%) ( p = 0.009). There were no differences with respect to G10 and Nassar 2019 scores in the visualization of the rest of the biliary structures when using ICG NIRF-C before and after dissection of Calot’s triangle. Regarding CLOC, CAAD scores and Surgical Time Score (CholeS Study Group), there were no differences in the visualization of the the biliary anatomy when using ICG NIRF-C before and after dissection of Calot’s triangle (Table 5). Discussion ICG ability to highlight blood perfusion and biliary anatomy has proven valuable in numerous surgical procedures, especially during complex cholecystectomies 10–28 . By enhancing the perception of biliary anatomical details, ICG significantly contributes to the precision of LC, thereby reducing the risk of conversion to open surgery, minimizing intraoperative complications such as BDIs, and improving the safety and effectiveness of ambulatory LC 19–23,26,28 . Impact of ICG on biliary anatomy visualization In our study, the use of indocyanine green (ICG) near-infrared fluorescence cholangiography (NIRF-C) significantly improved the visualization of key biliary structures, such as the common bile duct (CBD), cystic duct (CD), and cystic duct-bile duct junction (CDBDJ). These structures are essential landmarks in laparoscopic cholecystectomy because their clear identification is crucial for ensuring the critical view of safety, reducing the risk of bile duct injury, and completing the procedure without complications. Pre-dissection, the CBD was visualized in only 29% of cases, but this rate increased to 100% after the dissection of Calot’s triangle. This improvement in visualization has significant clinical implications, as it reduces the likelihood of bile duct injuries (BDIs), which are among the most severe complications during laparoscopic cholecystectomy. Similarly, the CD and CDBDJ were identified in 71% and 84% of patients, respectively, after dissection (p < 0.001 for all comparisons between pre- and post-dissection). These findings were observed in our study, aligning with those of Schols et al. 11 , who demonstrated that early biliary tract delineation with ICG facilitates safe surgery, especially in challenging cases (Table 2 ). In our study, ICG NIRF-C proved crucial for enhanced visualization of biliary structures, particularly in high-risk patients. Specifically, patients with CLOC > 6 , who face increased surgical complexity and a higher likelihood of needing conversion to open surgery, demonstrated notable benefits. These patients, constituting 61.4% of our cohort, exhibited improved delineation of biliary anatomy, which is often challenging to discern in complex cases. Post-dissection visualization rates for these patients were 74% for the cystic duct (CD) and 81.5% for the common bile duct junction (CDBDJ), compared to 65% and 88%, respectively, in patients with CLOC scores of 6 or less. This suggests a differential impact of fluorescence cholangiography based on surgical complexity, although the common bile duct (CBD) was visualized with 100% effectiveness in both groups, highlighting the method's overall reliability. The application of ICG provided real-time fluorescence guidance, significantly reducing the risk of structural misidentification and subsequent surgical complications. According to our findings, patients with G10 scores ≥ 3 , which predicts greater difficulty in identifying the biliary anatomy, pre-dissection visualization of the CBD was only 5.3%, compared to 48% in patients with G10 scores < 3. However, after dissection and the use of ICG, the CBD was identified in 100% of all cases, regardless of G10 score (p = 0.002 for G10 ≥ 3 vs. G10 < 3). This shows that ICG compensates for the difficulties predicted by the G10 score, facilitating clearer visualization in even the most challenging cases. This mirrors the results of Ishizawa et al. 10 , who demonstrated that the use of ICG can highlight biliary structures even in difficult cases, reducing the likelihood of BDI 10 (Table 3 ). Similarly, in our study, patients with Nassar scores ≥ 3 had more difficulty visualizing the biliary anatomy before dissection, with only 39% of patients with Nassar scores < 3 having their CBD visualized pre-dissection. After dissection and the use of ICG, the CBD was identified in all patients, regardless of the Nassar score (Table 3 ), reinforcing the crucial role of ICG in aiding complex surgeries. Reduction in conversion to open surgery According to CLOC score, the risk of conversion to open for low (CLOC ≤ 6) and high risk (CLOC > 6) patients is 1.2% and 7.1%, respectively. Hence, patients identified as high risk have a near six-fold higher rate of conversion than low risk patients 26 . It is notable that in the CLOC study, of the converted patients without intraoperative complications (N = 214), conversion was due to procedural difficulty (Nassar grade 3–4 or bile duct exploration) in the majority of cases (96%) 26 . Consequently, in patients with significant inflammation and/or fibrosis in the region of Calot’s triangle, accurate identification of anatomical landmarks may prove difficult or impossible using a laparoscopic approach 26 . In line with it, of the 27 patients (61,4%) with CLOC score > 6 in our serie, at least 2 patients should had been converted to open surgery. No conversions to open surgery were observed in these high-risk cases, underscoring the effectiveness of ICG in this context. Similarly, the G10 score showed that 43.2% of patients in this study had scores ≥ 3, which typically correlates with more challenging procedures. Despite this, ICG allowed for safe completion of all procedures laparoscopically without conversion to open surgery. Patients with G10 scores ≥ 5 have a 33% expected conversion rate 27 . Thus, of our 8 patients (18,2%) with G10 score ≥ 5, at least 2 of them should had been converted to open surgery. Nevertheless, they did not experience any conversions in this study, further demonstrating the effectiveness of ICG in managing complex cases. For predicting LC difficulty, Nassar Score (2019) offers the best balance of predictive accuracy, validation, and practical utility. Given its broad applicability and rigorous validation, this model may serve as the most reliable tool for preoperative risk assessment in patients undergoing LC 30 . According to this, intermediate scores (3–4 points) up to 40% likelihood of some difficulties, suggesting a moderate risk of conversion; and high scores (≥ 5 points) have over 80% chance of difficulties, often necessitating conversion to open surgery 30 . In our serie 13 patients (29,5%) had a intermediate score and 45.5% of patients had a high score. Despite this, ICG helped ensure that all surgeries were completed laparoscopically without complications or conversions. This echoes the conclusions of Nassar et al. ( 2019 ), who emphasized the importance of using advanced visualization techniques, such as ICG, to manage the challenges associated with high-risk patients (Table 2 ). This result is also strongly supported by the findings of Sutcliffe et al. 27 , who noted that improved visualization of biliary structures with fluorescence-guided surgery can significantly reduce conversion rates. In patients with Nassar scores ≥ 5 , who represent the most complex and difficult cases, the absence of conversions is particularly noteworthy. Studies by El-Sharkawy et al. 23 and Osayi et al. 23 corroborate this finding, demonstrating that ICG significantly reduces the risk of conversion in high-complexity cases by providing better visualization of the bile ducts and surrounding tissues, allowing surgeons to navigate through adhesions and anatomical challenges without resorting to open surgery. Reduction in operative time In our study, we hypothesized that the use of indocyanine green may improve surgical times even in intermediate/high risk cases by allowing better visualization of biliary structures and increasing the surgeon's confidence. In this manner, one of the most compelling findings of our study is the reduction in operative time when ICG is used. As detailed in Table 4 , ICG NIRF-C also contributed to a significant reduction in operative time, especially in high-risk patients. On average, surgeries in this study lasted 45 ± 15 minutes, with 56% of patients with G10 scores < 3 completing surgery in less than 45 minutes. However, the impact of ICG is even more pronounced in patients with G10 scores ≥ 3 , where only 16% of patients had surgeries exceeding 90 minutes (p = 0.01). This reduction in operative time has important implications for postoperative outcomes, including a potentially lower risk of complications and improved efficiency in the use of operating room resources, which are critical factors in optimizing surgical workflows. This is in line with Tsutsui et al. 15 , who found that the use of ICG reduced surgery times by improving intraoperative decision-making and dissection efficiency. Patients with G10 scores ≥ 5 , who typically face a 33% conversion rate and longer surgery durations 27 , saw operative times reduced significantly with ICG. Only 7% of these high-risk patients required more than 90 minutes for surgery (p = 0.03). These results align with and expand upon the findings from the CholeS Study Group 29 , which demonstrated that preoperative factors could predict longer surgeries. Our study builds on this by showing how the use of ICG mitigates these risks specifically through enhanced intraoperative visualization, resulting in improved outcomes even in high-complexity cases (Table 4 ). The impact of ICG in reducing operative time was also evident in patients classified with higher Surgical Time Score , a score validated in an independent cohort of 2405 patients and demonstrating good predictive capacity, with an area under the ROC curve of 0.708 29 . According to the CholeS Study Group, surgeries in patients with intermediate or high-risk scores are expected to exceed 90 minutes, but in this study and contrary to what might be expected, none of the high-risk patients had surgeries lasting over 90 minutes, thanks to the use of ICG. Bharamgoudar et al. 29 highlighted similar outcomes, where ICG helped reduce surgical times and improve resource allocation in complex cholecystectomy cases. Additionally, Sugrue et al. 26 demonstrated that accurate intraoperative visualization, especially in cases deemed complex by scores such as G10 and the Surgical Time Score (CholeS Study Group), can significantly reduce operative times, which directly correlates with our findings (Table 5 ). Expected percentage of candidate interventions for outpatient surgery according to CAAD score A CAAD score of ≦ 5 is associated with 80.8% successful day-case cholecystectomy compared with 19.2% associated with a CAAD score > 5 (p 5 , a group that typically has only a 19.2% chance of successful day-case surgery. Despite this, ICG allowed for the safe discharge of all patients the day after surgery, suggesting that ICG can help expand the eligibility for ambulatory cholecystectomy. In our serie, there were no day-case surgeries but in all patients LC was performed safely with the visualization of CBD in all surgeries and all patients were discharged the next day after surgery without postoperative complications or readmissions. This finding is supported by El-Sharkawy et al. 28 , who demonstrated that the use of ICG in high-risk day-case surgeries can significantly improve outcomes by reducing the incidence of complications that typically necessitate prolonged hospital stays (Table 5 ). Conclusion The findings of this study demonstrate that ICG NIRF-C significantly enhances biliary anatomy visualization, reduces operative time, and minimizes the need for conversion to open surgery, even in high-risk laparoscopic cholecystectomy cases. By improving intraoperative identification of key biliary structures, ICG facilitates safer dissection, particularly in patients with distorted anatomy, severe inflammation, or high surgical complexity as indicated by CLOC, G10, and Nassar scores. The ability of ICG to optimize intraoperative decision-making likely contributed to the zero-conversion rate observed in this study, despite a high proportion of patients classified as at-risk for conversion. Furthermore, the reduction in operative time associated with ICG use has both clinical and logistical benefits, lowering exposure to prolonged anesthesia, minimizing intraoperative complications, and improving operating room efficiency. These advantages extend to ambulatory laparoscopic cholecystectomy, where ICG may play a role in expanding patient eligibility for same-day discharge by reducing intraoperative risks and ensuring a safer recovery. These findings strongly support the integration of ICG fluorescence cholangiography as a standard tool in laparoscopic cholecystectomy, particularly in complex cases. Future multicentric studies with larger cohorts should further validate these results and explore the potential of ICG to refine risk stratification models and surgical decision-making in hepatobiliary surgery. Limitations of the study This study has several limitations. Firstly, it is a retrospective review based on patients submitted to LC, which increases the possibility of selection bias. Secondly, other important limitations of our study are the sample size and the lack of a control group which would give a higher validity to our conclusions. Moreover, to demonstrate other aims such as a potential reduction in BDIs, a larger sample would be needed. An external validation of the use of ICG in high risk scores would be helpful in order to corroborate the relationships we hypothesize. Furthermore, as a topic for further research, it would be interesting to create a new risk score for conversion to open surgery considering the biliary anatomy identified with ICG NIRF-C. Abbreviations laparoscopic cholecystectomy (LC), bile duct injury (BDI), indocyanine green (ICG), near-infrared fluorescence cholangiography (NIRF-C), near infrared (NIR), white light (WL), cystic duct (CD), common bile duct (CBD), cystic duct-bile duct junction (CDBDJ), visual analogue scale (VAS), Body Mass Index (BMI), American Society of Anaesthesiologists (ASA). Declarations The present study has been approved by the Research Committee of the Hospital Universitari Son Espases under reference number CI-344-19. It is registered in the U.S. Clinical Trials and Studies Database (ClinicalTrials.gov) with the identification number NCT04005898. Author contribution The corresponding author attests that all listed authors meet authorship criteria and that no other meeting the criteria have been omitted. The manuscript’s guarantor affirms that the manuscript is an honest, accurate and transparent account of the study being reported; no important aspects of the study have been omitted and any discrepancies from the study as planned have been explained. Drs. Natalia Pujol- Cano, Francesc Xavier Molina-Romero, Elías Palma-Zamora, Jaume Bonnin-Pascual, Magdalena Coll-Sastre, Francesc Xavier González- Argenté and José Miguel Morón-Canis have no conflicts of interest or financial ties to disclose. Competing interests The authors declare no competing interests. Conflict of interest All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work. References Perissat J (1993) Laparoscopic cholecystectomy: the European experience. Am J Surg 165(4):444–449 Nuzzo G, Giuliante F, Giovannini I, Ardito F, D’Acapito F et al (2005) Vel- lone M Bile duct injury during laparoscopic cholecystectomy: results of an Italian national survey on 56 591 cholecystectomies. Arch Surg 140(10):986–992 Tornqvist B, Stromberg C, Persson G, Nilsson M (2012) Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study. BMJ 345:e6457 Halbert C, Pagkratis S, Yang J, Meng Z, Altieri MS, Parikh P et al (2016) Beyond the learning curve: incidence of bile duct injuries following laparoscopic cholecystectomy normalize to open in the modern era. Surg Endosc 30(6):2239–2243 Flum DR, Dellinger EP, Cheadle A, Chan L, Koepsell T (2003) Intraoperative cholangiography and risk of common bile duct injury during cholecystectomy. JAMA 289(13):1639–1644 Pesce A, Portale TR, Minutolo V, Scilletta R, Li Destri G, Puleo S (2012) Bile duct injury during laparoscopic cholecystectomy without intraoperative cholangiography: a retrospective study on 1,100 selected patients. Dig Surg 29(4):310–314 Machado NO (2011) Biliary complications postlaparoscopic cholecystectomy: mechanism, preventive measures, and approach to management: a review. Diagn Ther Endosc 2011:967017 Kum CK, Eypasch E, Lefering R, Paul A, Neugebauer E, Troidl H (1996) Laparoscopic cholecystectomy for acute cholecystitis: is it really safe? World J Surg 20(1):43–48 Booij KA, de Reuver PR, Yap K, van Dieren S, van Delden OM, Rauws EA et al (2015) Morbidity and mortality after minor bile duct injury following laparoscopic cholecystectomy. Endoscopy 47(1):40–46 Ishizawa T, Bandai Y, Ijichi M, Kaneko J, Hasegawa K, Kokudo N (2010) Fluorescent cholangiography illuminating the biliary tree during laparoscopic cholecystectomy. Br J Surg 97(9):1369–1377 Schols RM, Bouvy ND, Masclee AA, van Dam RM, Dejong CH, Stassen LP (2013) Fluorescence cholangiography during laparoscopic cholecystectomy: a feasibility study on early biliary tract delineation. Surg Endosc 27(5):1530–1536 Dip F, LoMenzo E, Sarotto L, Phillips E, Todeschini H, Nahmod M et al (2019) Randomized trial of near-infrared incisionless fluorescent cholangiography. Ann Surg 270(6):992–999 Cherrick GR, Stein SW, Leevy CM, Davidson CS (1960) Indocyanine green: observations on its physical properties, plasma decay, and hepatic extraction. J Clin Invest 39:592–600 Zarrinpar A, Dutson EP, Mobley C, Busuttil RW, Lewis CE, Tillou A et al (2016) Intraoperative laparoscopic near-infrared fluorescence cholangiography to facilitate anatomical identification: when to give indocyanine green and how much. Surg Innov 23(4):360–365 Tsutsui N, Yoshida M, Nakagawa H, Ito E, Iwase R, Suzuki N et al (2018) Optimal timing of preoperative indocyanine green admin- istration for fluorescent cholangiography during laparoscopic cholecystectomy using the PINPOINT(R) Endoscopic Fluorescence Imaging System. Asian J Endosc Surg 11(3):199–205 Agnus V, Pesce A, Boni L, Van Den Bos J, Morales-Conde S, Paganini AM et al 2019 Fluorescence-based cholangiography: preliminary results from the IHU-IRCAD-EAES EURO-FIGS registry. Surg Endosc Nassar AHM, Ashkar KA, Mohamed AY, Hafiz AA (1995) Is laparoscopic cholecystectomy possible without video technology? Minim Invasive Ther Allied Technol 4:63–65 Diana M, Soler L, Agnus V, D’Urso A et al (2017) Prospective evaluation of precision multimodal gallbladder surgery navigation virtual reality, near-infrared fluorescence, and X-ray-based intraoperative cholangiography. Ann Surg 266:890–897 Pesce A, Piccolo G, La Greca G, Puleo S (2015) Utility of fluorescent cholangiography during laparoscopic cholecystectomy: a systematic review. World J Gastroenterol 21(25):7877–7883 Kono Y, Ishizawa T, Tani K, Harada N et al 2015 Techniques of fluorescence cholangiography during laparoscopic cholecystectomy for better delineation of the bile duct anatomy. Medicine; 94(25) Chen Q, Zhou R, Weng J, Lai Y et al 2020 Extrahepatic biliary tract visualization using near-infrared fluorescence imaging with indocyanine green: optimization of dose and dosing time. Surg Endosc Hiwatashi K, Okumura H, Setoyama T, Ando K, Ogura Y et al 2018 Evaluation of laparoscopic cholecystectomy using indocyanine green cholangiography including cholecystitis. A retrospective study. Medicine; 97(30) Osayi S, Wendling M, Drosdeck JM, Chaudhry UI et al (2015) Near-infrared fluorescent cholangiography facilitates identification of biliary anatomy during laparoscopic cholecystectomy. Surg Endosc 29:368–375 Dindo D et al (2004) Classification of surgical complications. Ann Surg 240(2):205–213 Strasberg SM, Hertl M, Soper NJ (1995) An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 180:101–125 Sugrue M, Coccolini F, Bucholc M, Johnston A, Contributors WSES (2019) Intra-operative gallbladder scoring predicts conversion of laparoscopic to open cholecystectomy: a WSES prospective collaborative study. World Journal of Emergency Surgery , 14 (1), 12 Sutcliffe RP, Hollyman M, Hodson J, Bonney G, Vohra RS, Griffiths EA, Fenwick S, Elmasry M, Nunes Q, Kennedy D, Khan RB, Khan MAS, Magee CJ, Jones SM, Mason D, Parappally CP, Mathur P, Saunders M, Jamel S, Shenoy H (2016) Preoperative risk factors for conversion from laparoscopic to open cholecystectomy: a validated risk score derived from a prospective U.K. database of 8820 patients. HPB: official J Int Hepato Pancreato Biliary Association 18(11):922–928 El-Sharkawy AM, Tewari N, Vohra RS, CholeS Study Group, West Midlands Research Collaborative (2023) Correction: The cholecystectomy as A day case (CAAD) score: A validated score of preoperative predictors of successful day-case cholecystectomy using the CholeS data set. World J Surg 47(4):1082 Bharamgoudar R, Sonsale A, Hodson J, Griffiths E (2018) The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy. Surg Endosc 32(8):3149–3157 Nassar AHM, Hodson J, Ng HJ, Vohra RS, Katbeh T, Zino S, Griffiths EA (2019) Predicting the difficult laparoscopic cholecystectomy: Development and validation of a pre-operative risk score using an objective operative difficulty grading system. Surg Endosc 33(12):1–15 Tables Tables 1 to 5 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.docx Table2.docx Table3.docx Table4.docx Table5.docx Cite Share Download PDF Status: Published Journal Publication published 14 Jan, 2026 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted Editorial decision: Revision requested 16 Aug, 2025 Reviews received at journal 14 Aug, 2025 Reviews received at journal 09 Aug, 2025 Reviewers agreed at journal 30 Jul, 2025 Reviewers agreed at journal 29 Jul, 2025 Reviewers agreed at journal 27 Jul, 2025 Reviewers agreed at journal 27 Jul, 2025 Reviewers agreed at journal 26 Jul, 2025 Reviewers agreed at journal 26 Jul, 2025 Reviews received at journal 24 Jul, 2025 Reviewers agreed at journal 24 Jul, 2025 Reviewers agreed at journal 24 Jul, 2025 Reviewers invited by journal 24 Jul, 2025 Editor assigned by journal 19 Jun, 2025 Submission checks completed at journal 19 Jun, 2025 First submitted to journal 15 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6900172","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":491542269,"identity":"e5fcefa1-dc99-4b40-b154-e5b69804b1ec","order_by":0,"name":"Natalia 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This minimally invasive technique offers numerous advantages, such as faster recovery, reduced postoperative pain, and shorter hospital stays\u003csup\u003e1,7\u0026ndash;9\u003c/sup\u003e. Additionally, ambulatory LC has gained recognition as a safe and effective procedure, enabling faster recovery in a home setting\u003csup\u003e8,9\u003c/sup\u003e. However, conversion to open surgery remains a challenging necessity in certain cases due to severe inflammation, anatomical variations, or extensive adhesions. These factors increase the difficulty of identifying biliary anatomy, leading to higher morbidity, longer hospitalizations, and significantly increased costs\u003csup\u003e2,4,7,9\u003c/sup\u003e. Notably, the primary cause of bile duct injury (BDI) in up to 97% of cases is misinterpretation of biliary structures\u003csup\u003e5,6\u003c/sup\u003e. In this context, contrast agents such as indocyanine green (ICG) have emerged as promising tools to enhance intraoperative visualization of the biliary tree, potentially reducing complications, shortening surgical times, and preventing conversions to open surgery\u003csup\u003e10\u0026ndash;12\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn this study, we aimed to evaluate the impact of indocyanine green near-infrared fluorescence cholangiography (ICG NIRF-C) in laparoscopic cholecystectomy (LC), particularly in high-risk cases, by analyzing its effect on biliary structure visualization, conversion to open surgery, operative time, and potential implications for ambulatory surgery. To support these claims, we examine five predictive scoring systems: CLOC, G10, CAAD, the Nassar Score (2019), and the Surgical Time Score (CholeS Study Group).\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eTrial design and patients\u003c/h2\u003e\u003cp\u003eThis was a descriptive study. Ethical clearance for the study was granted by the institutional review board, designated as CI-344-19. Patients underwent surgery between January 2019 and January 2020. All surgeries were performed by the same surgical team, thus neutralizing any bias with respect to observation of the biliary anatomy while using ICG NIRF-C. Those patients with a prior history of symptomatic cholelithiasis such as biliary colic, acute or chronic cholecystitis, choledocholithiasis, pancreatitis or gallbladder polyps were enrolled in the study to undergo LC with NIR-ICG fluorescence imaging. Other inclusion criteria were age\u0026thinsp;\u0026ge;\u0026thinsp;18 years old, normal liver and kidney function, no allergies to ICG or iodine, ability to understand and follow study procedures and having provided signed consent. The exclusion criteria were age\u0026thinsp;\u0026lt;\u0026thinsp;18 years old, liver or kidney dysfunction, known history of cholangitis or prior common bile duct injury, allergy to ICG or iodine, pregnancy or breast-feeding and inability to understand and follow study procedures.\u003c/p\u003e\u003cp\u003eNone of the patients was taking medication interfering with hepatic ICG uptake.\u003c/p\u003e\u003cp\u003eThe patient withdrawal criteria were withdrawal of informed consent or lost to follow-up.\u003c/p\u003e\u003cp\u003ePatient data were collected at enrolment, during surgery, immediately after surgery and up to 90 days postoperatively.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOutcomes measures\u003c/h3\u003e\n\u003cp\u003eThe data recorded included age, gender, diabetes mellitus, hypertension, dyslipidaemia, body mass index (BMI), American Society of Anaesthesiologists (ASA) physical status classification, surgical indication, intraoperative complications, hepatic hyperluminescence, visualization of biliary structures such as the cystic duct (CD), the common bile duct (CBD) and the cystic duct\u0026ndash;bile duct junction (CDBDJ) before and after dissection of Calot\u0026rsquo;s triangle, conversion to open surgery, postoperative complications graded according to the Clavien\u0026ndash;Dindo classification\u003csup\u003e24\u003c/sup\u003e, BDI described according to Strasberg classification\u003csup\u003e25\u003c/sup\u003e, hospital stay and readmission.\u003c/p\u003e\u003cp\u003eIn our study, we have also used the Nassar classification\u003csup\u003e17\u003c/sup\u003e to perform a visual intraoperative assessment of the surgical difficulty at the beginning of each cholecystectomy given that it is easy to use and reproducible and reflects the tendency to suffer from BDIs as well as prolonged surgical times and conversion to open surgery. The Nassar scale grades operative findings\u003csup\u003e17\u003c/sup\u003e from the gallbladder, cystic pedicle and associated adhesions. In grade 1, the gallbladder is floppy and non-adherent, the cystic pedicle is thin and clear, and the adhesions are simple up to the neck/Hartmann\u0026rsquo;s pouch. In grade 2, the gallbladder can be packed with stones, the cystic pedicle is fat laden, and adhesions are simple up to the body. In grade 3, the gallbladder can have a deep fossa, acute cholecystitis and fibrosis, and Hartmann\u0026rsquo;s pouch is adherent/impacted to CBD. The cystic pedicle can have abnormal anatomy, or the cystic duct is short, dilated or obscured. Adhesions are dense up to the fundus or involving hepatic flexure or duodenum. In grade 4, the gallbladder is completely obscured or can have empyema or gangrene. The cystic pedicle is impossible to clarify, and adhesions are dense with fibrosis, wrapping the gallbladder. The duodenum and/or hepatic flexure are difficult to separate.\u003c/p\u003e\u003cp\u003eOn the other hand, when we analyse the variable \u0026ldquo;gallbladder inflammation\u0026rdquo;, it corresponds to the pathological anatomy of the surgical specimen and is classified as absence of inflammation, acute inflammation, or chronic inflammation.\u003c/p\u003e\n\u003ch3\u003eSurgical and fluorescence cholangiography techniques\u003c/h3\u003e\n\u003cp\u003eICG is a fluorophore that, when administered intravenously, binds to plasma proteins and is primarily eliminated by the liver enhancing the perception of biliary anatomy\u003csup\u003e10\u0026ndash;28\u003c/sup\u003e. A unique dose of 0.25 mg of ICG dye was administered intravenously 15 min before the surgery during the anaesthesia induction. After placing ports, the scope was introduced into the abdominal cavity. We then exposed the gallbladder in order to visualize Calot\u0026rsquo;s triangle and recorded the exact moment when Calot\u0026rsquo;s triangle first became visible by ICG NIRF-C imaging before performing dissection. We confirmed the absence of aberrant bile ducts and then bluntly dissected Calot\u0026rsquo;s triangle after achieving the \u0026ldquo;critical view of safety\u0026rdquo; described by Strasberg and isolating the cystic duct and cystic artery with ICG NIRF-C in overlay mode. The cystic duct and cystic artery were clipped and divided after confirming the CDBDJ using fluorescence cholangiography. We then dissected the gallbladder from the liver bed. Upon completion of all laparoscopic procedures, we performed NIRF-C again to examine the cystic duct stump and confirm the absence of any bile leakage. Finally, the gallbladder was removed from the abdomen using a retrieval bag.\u003c/p\u003e\n\u003ch3\u003eLaparoscopic equipment\u003c/h3\u003e\n\u003cp\u003eWe used the VISERA ELITE II Surgical Endoscope System (Olympus Corporation, Shinjuku, Tokyo, Japan) for NIR/ ICG imaging with a 30\u0026deg; forward oblique laparoscope. NIR images were obtained by combining an infrared light source and infrared telescope with the video system centre, camera head and monitor used for white light (WL) images. Images can be switched between WL and NIR light by pushing a button conveniently located on the camera head. The OTV-S300 video system centre uses an LED light source instead of a xenon lamp. During LC, alternating exposure to WL to NIR light sources can be used to identify biliary structures before, during and after dissection. In overlay mode, the regular WL image is combined with the NIR/ICG data to generate an overlay image. In our study, we performed all surgeries in overlay mode in order to identify each ICG stained biliary structure while dissecting Calot\u0026rsquo;s triangle.\u003c/p\u003e\n\u003ch3\u003ePredictive Scoring Systems\u003c/h3\u003e\n\u003cp\u003eWe have also investigated the relationship between ICG NIRF-C during LC and five surgical risk assessment systems: CLOC\u003csup\u003e27\u003c/sup\u003e, G10\u003csup\u003e26\u003c/sup\u003e, Nassar Score (2019)\u003csup\u003e30\u003c/sup\u003e, CAAD\u003csup\u003e28\u003c/sup\u003e and the Surgical Time Score\u003csup\u003e29\u003c/sup\u003e (from the CholeS Study Group). These scoring systems were chosen because they provide valuable insights into key surgical challenges, such as predicting conversion to open surgery, assessing surgical complexity, and estimating operative time.\u003c/p\u003e\u003cp\u003eThe CLOC score is a validated preoperative risk assessment tool designed to predict the likelihood of conversion from laparoscopic to open cholecystectomy\u003csup\u003e27\u003c/sup\u003e. As described in this study, we have also stratified patients as \u003cb\u003ehigher risk of conversion\u003c/b\u003e if they had a \u003cb\u003eCLOC score\u0026thinsp;\u0026gt;\u0026thinsp;6\u003c/b\u003e\u003csup\u003e27\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe G10 score is an intraoperative gallbladder scoring system prospectively evaluated to predict surgical outcomes, particularly the feasibility of completing the operation laparoscopically\u003csup\u003e26\u003c/sup\u003e. This scoring system was developed in a multicenter study led by the World Society of Emergency Surgery\u003csup\u003e26\u003c/sup\u003e. Gallbladder surgery was considered easy if the G10 score\u0026thinsp;\u0026lt;\u0026thinsp;2, moderate (2\u0026thinsp;≦\u0026thinsp;4), difficult (5\u0026thinsp;≦\u0026thinsp;7) and extreme (8\u0026thinsp;≦\u0026thinsp;10)\u003csup\u003e26\u003c/sup\u003e. The optimal cut-off point of 0.067 (score of 3) was identified in G10 and conversion to open cholecystectomy occurred in 33% of patients with G10 scores of \u0026ge;\u0026thinsp;5\u003csup\u003e26\u003c/sup\u003e. We categorized our patients at \u003cb\u003ehigher risk of conversion to open surgery\u003c/b\u003e with G10 scores meeting the following thresholds: \u003cb\u003eG10\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/b\u003e (moderate or higher difficulty) and \u003cb\u003eG10\u0026thinsp;\u0026ge;\u0026thinsp;5\u003c/b\u003e (difficult or extreme cases).\u003c/p\u003e\u003cp\u003eThe \u003cb\u003eNassar scoring system (2019)\u003c/b\u003e is a predictive tool for assessing surgical difficulty in laparoscopic cholecystectomy and estimating the likelihood of conversion to open surgery based on operative findings\u003csup\u003e30\u003c/sup\u003e. It classifies cases into three risk levels\u0026mdash;low (0\u0026ndash;2 points), intermediate (3\u0026ndash;4 points), and high (\u0026ge;\u0026thinsp;5 points)\u0026mdash;to help anticipate surgical complexity, prolonged operative times, and potential complications\u003csup\u003e30\u003c/sup\u003e. In our study, patients were stratified accordingly into these three categories.\u003c/p\u003e\u003cp\u003eThe CAAD score is a validated system for predicting the success of day-case cholecystectomy operations)\u003csup\u003e28\u003c/sup\u003e. It was developed using data from a prospectively collected dataset of cholecystectomy patients from 166 UK and Irish hospitals (CholeS study))\u003csup\u003e28\u003c/sup\u003e. This score is based on 10 preoperative factors, including patient demographics (age and gender), comorbidities (ASA score), history of previous hospital admissions for gallstone-related disease, primary indication for surgery (such as biliary colic, cholecystitis, or choledocholithiasis), preoperative imaging findings (thickened gallbladder wall or dilated common bile duct), and the type of preoperative investigations performed (radiological or endoscopic)\u003csup\u003e28\u003c/sup\u003e. Patients were identified as having a greater risk of unsuccessful day-case cholecystectomy if their \u003cb\u003eCAAD score\u0026thinsp;\u0026gt;\u0026thinsp;5\u003c/b\u003e\u003csup\u003e28\u003c/sup\u003e. By incorporating these variables, the CAAD score provides an objective tool for preoperative patient selection, optimizing surgical planning and resource allocation.\u003c/p\u003e\u003cp\u003eFinally, the \u003cb\u003eSurgical Time Score\u003c/b\u003e was developed to predict whether \u003cb\u003ea surgery will exceed 90 minutes\u003c/b\u003e, helping to optimize operating room scheduling\u003csup\u003e29\u003c/sup\u003e. This score is based on 10 preoperative factors and categorizes patients into low (0\u0026ndash;3 points), intermediate (4\u0026ndash;7 points), or high risk (8 points or more) for prolonged operative time\u003csup\u003e29\u003c/sup\u003e. It has been validated and shown to improve efficiency in surgical planning\u003csup\u003e29\u003c/sup\u003e. In our study, the surgical times were also divided into three categories: less than 45 minutes, between 45 and 90 minutes, and more than 90 minutes.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eNormality tests and graphs were used to determine whether variables followed a normal distribution. Data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) for continuous variables, and those a non-normal distribution are expressed as median values and interquartile ranges. We used Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e test or the Wilcoxon test for paired samples for the quantitative variables. The Chi-square test and McNemar\u0026rsquo;s test were used for qualitative variables. Pearson\u0026rsquo;s correlation coefficient was used to determine the linear dependence between two quantitative variables. ANOVA test was used to compare continuous variable means of two or more groups. Linear regression analysis was also performed to assess the association of continuous variables. A \u003cem\u003ep\u003c/em\u003e value of less than 0.05 was considered statistically significant. Statistical analyses were carried out with SPSS software 23.0 (SPSS Inc., Chicago, IL, USA).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eForty-four patients (16 females (36%) and 28 males (64%)) were eligible for elective LC and included in our study. The mean age was 57±15 years. According to ASA score, 9 patients (20%) were ASA I, 24 (55%) were ASA II, and 11 (25%) were ASA III. Their mean BMI was 28 ± 5 kg/m2. The mean operation time was 45±15 min. The indications for surgery were 13 cases of symptomatic cholelithiasis (30%), 7 of choledocholithiasis (treated with preoperative endoscopic retrograde cholangiopancreatography) (16%), 12 of previous cholecystitis (27%) and 12 of lithiasic pancreatitis (27%). Twenty patients (45%) did not have gallbladder inflammation, 22 (50%) had chronic inflammation, and only 2 (5%) had acute inflammation. When classifying patients according to their Nassar grade, 20 (45%) were grade 1, 13 (29%) were grade 2, 8 (18%) were grade 3, and only 3 patients (7%) were grade 4.\u003c/p\u003e\n\u003cp\u003eICG NIRF-C was performed during LC in all 44 cases. No allergic reactions to ICG were reported. There were no BDIs and no conversions to laparotomy. The postoperative course was free of complications in all cases. The mean postoperative hospital stay was 28±4 h. No hospital readmissions were recorded. All other patient characteristics, intraoperative data and postoperative outcomes are reported in Table\u0026nbsp;1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbility of fluorescence cholangiography to delineate the bile duct anatomy\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe CD or the CDBDJ could not be identified via fluorescence cholangiography in any of the patients before dissection of Calot’s triangle, whereas the CBD was detected using ICG NIRF-C in 13 patients (29%) before dissection of Calot’s triangle (Table\u0026nbsp;2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter dissecting Calot’s triangle (at average time of 25 min after starting surgery), ICG NIRF-C identified the CD and the CDBDJ in 31 (71%) and 37 (84%) patients, respectively. The CBD was detected in all 44 patients with ICG NIRF-C after dissection of Calot’s triangles. Statistically significant differences in the identification of the three bile structures using ICG NIRF-C were found before and after the dissection of Calot’s triangle (Table\u0026nbsp;2). No accessory bile ducts were identified in any of the LC interventions during ICG NIRF-C. No hepatic hyperluminescence was observed in any of the patients at an ICG dose of 0.25 mg.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical factors affecting the ability of fluorescence cholangiography to delineate the bile duct anatomy\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;3 summarizes the effects of clinical factors such as obesity and the degree of inflammation on the ability of ICG NIRF-C to delineate bile duct anatomy before and after dissecting Calot’s triangle.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe observed statistically significant differences in the visualization of the CBD using ICG NIRF-C before dissecting Calot’s triangle in patients with a Nassar grade \u0026lt; 3 (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.013) and no gallbladder inflammation (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.001). In this manner, ICG NIRF-C could detect the CBD in 13 patients (39%) with a Nassar grade \u0026lt; 3 before dissection of Calot’s triangle and in 20 patients (65%) without gallbladder inflammation. There were no differences with respect to these clinical factors in the visualization of the rest of the biliary structures when using ICG NIRF-C before and after dissection of Calot’s triangle except for the post- dissection visualization of the CDBDJ in patients with no gallbladder inflammation (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.008) (Table\u0026nbsp;3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRelationship between\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCLOC, G10, CAAD, Nassar 2019 Scores and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eand Surgical Time Score (CholeS Study Group)\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eand the Duration of Surgery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 4 summarizes\u0026nbsp;the relationship between CLOC, G10,\u0026nbsp;CAAD\u0026nbsp;and Nassar 2019\u0026nbsp;Scores and\u0026nbsp;surgical times. Statistically significant differences were only observed in patients with\u0026nbsp;G10\u0026nbsp;score\u0026nbsp;≥ 3\u0026nbsp;(p = 0.01) and\u0026nbsp;G10\u0026nbsp;score\u0026nbsp;≥\u0026nbsp;5 (p = 0.03).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this manner, 14 patients (56%) with G10 \u0026lt; 3 had a surgical time \u0026lt;45 min; 11 (44%) had a surgical time between 45 - 90 min and none of the patients with G10 \u0026lt; 3 had a surgical time \u0026gt;90 min. Four patients (21%) with G10 ≥ 3 had a surgical time \u0026lt;45 min; 12 (63%) had a surgical time between 45 - 90 min and 3 (16%) had a surgical time \u0026gt;90 min.\u003c/p\u003e\n\u003cp\u003eOn the other hand, 17 patients (47%) with G10 \u0026lt; 5 had a surgical time \u0026lt;45 min; 18 (50%) had a surgical time between 45 - 90 min and 1 patient (2.8%) had a surgical time \u0026gt;90 min. One patient (12.5%) with G10 ≥ 5 had a surgical time \u0026lt;45 min; 5 (62.5%) had a surgical time between 45 - 90 min and 2 (7%) had a surgical time \u0026gt;90 min.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our study, there were only 3 patients with a surgical intervention lasting more than 90 minutes, which corresponded to an intermediate score according to the Surgical Time Score (CholeS Study Group).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRelationship between the ability of fluorescence cholangiography to delineate the bile duct anatomy before and after dissection of Calot’s triangle and CLOC, G10, CAAD, Nassar 2019\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Risk Scores\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eSurgical Time Score (CholeS Study Group)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwenty-seven patients (61,4%) had a CLOC \u0026nbsp;score \u0026gt; 6, 19 patients (43,2%) had G10 score ≥ 3, 8 patients (18,2%) had G10 score ≥ 5 and 28 (63,6%) had a CAAD score \u0026gt; 5. Regarding surgical Time Score (CholeS Study Group), nine patients (20.4%) had a low score, 32 (72.7%) had a intermediate score and 3 (6.8%) had a high score. Finally, eleven patients (25%) had a low Nassar Score 2019, 13 (29.5%) had a intermediate score and 20 (45.5%) had a high score.\u003c/p\u003e\n\u003cp\u003eThe mean, median, mode and standard deviation of CLOC score were 7.4, 7, 7 and +/-2.7; respectively. G10 score’s mean, median, mode and standard deviation were 2.6, 2, 1 and +/-1.6; respectively. The mean, median, mode and standard deviation of CAAD score were 6.4, 6, 6, +/-2.8, respectively. Mean, median, mode and standard deviation of Nassar score (2019) were 4.3, 4, 3 and +/-2.4; respectively. Finally, Surgical Time Score’s\u0026nbsp;mean, median, mode and standard deviation were 4.5, 4.25, 3.5 and +/-1.8; respectively.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;5\u0026nbsp;shows the relationship between the ability of ICG NIRF-C to delineate bile duct anatomy before and after dissecting Calot’s triangle and the mentioned scores.\u003c/p\u003e\n\u003cp\u003eWe observed statistically significant differences in the visualization of the CBD using ICG NIRF-C before dissecting Calot’s triangle in patients with G10 ≥ 3 (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.002), G10 ≥ 5 (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.043) and Nassar score 2019. Thus, ICG NIRF-C could detect the CBD in 12 patients (48%) with a G10 \u0026lt; 3 before dissection of Calot’s triangle and in only 1 patient (5.3%) with a G10 ≥ 3. Similary, ICG NIRF-C could detect the CBD in 13 patients (36%) with a G10 \u0026lt; 5 before dissection of Calot’s triangle and in none of the patients with a G10 ≥ 5. Regarding Nassar score 2019, ICG NIRF-C could detect the CBD before dissection of Calot’s triangle in 7 patients with low score (63.6%), 1 patient with intermediate score (7.7%) and 5 patients with high score (25%) (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.009). There were no differences with respect to G10 and Nassar 2019 scores in the visualization of the rest of the biliary structures when using ICG NIRF-C before and after dissection of Calot’s triangle.\u003c/p\u003e\n\u003cp\u003eRegarding CLOC, CAAD scores and Surgical Time Score (CholeS Study Group), there were no differences in the visualization of the the biliary anatomy when using ICG NIRF-C before and after dissection of Calot’s triangle (Table\u0026nbsp;5).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eICG ability to highlight blood perfusion and biliary anatomy has proven valuable in numerous surgical procedures, especially during complex cholecystectomies\u003csup\u003e10\u0026ndash;28\u003c/sup\u003e. By enhancing the perception of biliary anatomical details, ICG significantly contributes to the precision of LC, thereby reducing the risk of conversion to open surgery, minimizing intraoperative complications such as BDIs, and improving the safety and effectiveness of ambulatory LC\u003csup\u003e19\u0026ndash;23,26,28\u003c/sup\u003e.\u003c/p\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eImpact of ICG on biliary anatomy visualization\u003c/h2\u003e\u003cp\u003eIn our study, the use of indocyanine green (ICG) near-infrared fluorescence cholangiography (NIRF-C) significantly improved the visualization of key biliary structures, such as the common bile duct (CBD), cystic duct (CD), and cystic duct-bile duct junction (CDBDJ). These structures are essential landmarks in laparoscopic cholecystectomy because their clear identification is crucial for ensuring the critical view of safety, reducing the risk of bile duct injury, and completing the procedure without complications. Pre-dissection, the CBD was visualized in only 29% of cases, but this rate increased to 100% after the dissection of Calot\u0026rsquo;s triangle. This improvement in visualization has significant clinical implications, as it reduces the likelihood of bile duct injuries (BDIs), which are among the most severe complications during laparoscopic cholecystectomy. Similarly, the CD and CDBDJ were identified in 71% and 84% of patients, respectively, after dissection (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for all comparisons between pre- and post-dissection). These findings were observed in our study, aligning with those of Schols et al.\u003csup\u003e11\u003c/sup\u003e, who demonstrated that early biliary tract delineation with ICG facilitates safe surgery, especially in challenging cases (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn our study, ICG NIRF-C proved crucial for enhanced visualization of biliary structures, particularly in high-risk patients. Specifically, patients with \u003cb\u003eCLOC\u0026thinsp;\u0026gt;\u0026thinsp;6\u003c/b\u003e, who face increased surgical complexity and a higher likelihood of needing conversion to open surgery, demonstrated notable benefits. These patients, constituting 61.4% of our cohort, exhibited improved delineation of biliary anatomy, which is often challenging to discern in complex cases. Post-dissection visualization rates for these patients were 74% for the cystic duct (CD) and 81.5% for the common bile duct junction (CDBDJ), compared to 65% and 88%, respectively, in patients with CLOC scores of 6 or less. This suggests a differential impact of fluorescence cholangiography based on surgical complexity, although the common bile duct (CBD) was visualized with 100% effectiveness in both groups, highlighting the method's overall reliability. The application of ICG provided real-time fluorescence guidance, significantly reducing the risk of structural misidentification and subsequent surgical complications.\u003c/p\u003e\u003cp\u003eAccording to our findings, patients with \u003cb\u003eG10 scores\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/b\u003e, which predicts greater difficulty in identifying the biliary anatomy, pre-dissection visualization of the CBD was only 5.3%, compared to 48% in patients with G10 scores\u0026thinsp;\u0026lt;\u0026thinsp;3. However, after dissection and the use of ICG, the CBD was identified in 100% of all cases, regardless of G10 score (p\u0026thinsp;=\u0026thinsp;0.002 for G10\u0026thinsp;\u0026ge;\u0026thinsp;3 vs. G10\u0026thinsp;\u0026lt;\u0026thinsp;3). This shows that ICG compensates for the difficulties predicted by the G10 score, facilitating clearer visualization in even the most challenging cases. This mirrors the results of Ishizawa et al.\u003csup\u003e10\u003c/sup\u003e, who demonstrated that the use of ICG can highlight biliary structures even in difficult cases, reducing the likelihood of BDI\u003csup\u003e10\u003c/sup\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSimilarly, in our study, patients with \u003cb\u003eNassar scores\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/b\u003e had more difficulty visualizing the biliary anatomy before dissection, with only 39% of patients with Nassar scores\u0026thinsp;\u0026lt;\u0026thinsp;3 having their CBD visualized pre-dissection. After dissection and the use of ICG, the CBD was identified in all patients, regardless of the Nassar score (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), reinforcing the crucial role of ICG in aiding complex surgeries.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eReduction in conversion to open surgery\u003c/h2\u003e\u003cp\u003eAccording to CLOC score, the risk of conversion to open for low (CLOC\u0026thinsp;\u0026le;\u0026thinsp;6) and high risk (CLOC\u0026thinsp;\u0026gt;\u0026thinsp;6) patients is 1.2% and 7.1%, respectively. Hence, patients identified as high risk have a near six-fold higher rate of conversion than low risk patients\u003csup\u003e26\u003c/sup\u003e. It is notable that in the CLOC study, of the converted patients without intraoperative complications (N\u0026thinsp;=\u0026thinsp;214), conversion was due to procedural difficulty (Nassar grade 3\u0026ndash;4 or bile duct exploration) in the majority of cases (96%)\u003csup\u003e26\u003c/sup\u003e. Consequently, in patients with significant inflammation and/or fibrosis in the region of Calot\u0026rsquo;s triangle, accurate identification of anatomical landmarks may prove difficult or impossible using a laparoscopic approach\u003csup\u003e26\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn line with it, of the 27 patients (61,4%) with CLOC score\u0026thinsp;\u0026gt;\u0026thinsp;6 in our serie, at least 2 patients should had been converted to open surgery. No conversions to open surgery were observed in these high-risk cases, underscoring the effectiveness of ICG in this context.\u003c/p\u003e\u003cp\u003eSimilarly, the \u003cb\u003eG10 score\u003c/b\u003e showed that 43.2% of patients in this study had scores\u0026thinsp;\u0026ge;\u0026thinsp;3, which typically correlates with more challenging procedures. Despite this, ICG allowed for safe completion of all procedures laparoscopically without conversion to open surgery. Patients with \u003cb\u003eG10 scores\u0026thinsp;\u0026ge;\u0026thinsp;5\u003c/b\u003e have a 33% expected conversion rate\u003csup\u003e27\u003c/sup\u003e. Thus, of our 8 patients (18,2%) with G10 score\u0026thinsp;\u0026ge;\u0026thinsp;5, at least 2 of them should had been converted to open surgery. Nevertheless, they did not experience any conversions in this study, further demonstrating the effectiveness of ICG in managing complex cases.\u003c/p\u003e\u003cp\u003eFor predicting LC difficulty, Nassar Score (2019) offers the best balance of predictive accuracy, validation, and practical utility. Given its broad applicability and rigorous validation, this model may serve as the most reliable tool for preoperative risk assessment in patients undergoing LC\u003csup\u003e30\u003c/sup\u003e. According to this, intermediate scores (3\u0026ndash;4 points) up to 40% likelihood of some difficulties, suggesting a moderate risk of conversion; and high scores (\u0026ge;\u0026thinsp;5 points) have over 80% chance of difficulties, often necessitating conversion to open surgery\u003csup\u003e30\u003c/sup\u003e. In our serie 13 patients (29,5%) had a intermediate score and 45.5% of patients had a high score. Despite this, ICG helped ensure that all surgeries were completed laparoscopically without complications or conversions. This echoes the conclusions of Nassar et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), who emphasized the importance of using advanced visualization techniques, such as ICG, to manage the challenges associated with high-risk patients (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This result is also strongly supported by the findings of Sutcliffe et al.\u003csup\u003e27\u003c/sup\u003e, who noted that improved visualization of biliary structures with fluorescence-guided surgery can significantly reduce conversion rates. In patients with \u003cb\u003eNassar scores\u0026thinsp;\u0026ge;\u0026thinsp;5\u003c/b\u003e, who represent the most complex and difficult cases, the absence of conversions is particularly noteworthy. Studies by El-Sharkawy et al.\u003csup\u003e23\u003c/sup\u003e and Osayi et al.\u003csup\u003e23\u003c/sup\u003e corroborate this finding, demonstrating that ICG significantly reduces the risk of conversion in high-complexity cases by providing better visualization of the bile ducts and surrounding tissues, allowing surgeons to navigate through adhesions and anatomical challenges without resorting to open surgery.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eReduction in operative time\u003c/h2\u003e\u003cp\u003eIn our study, we hypothesized that the use of indocyanine green may improve surgical times even in intermediate/high risk cases by allowing better visualization of biliary structures and increasing the surgeon's confidence. In this manner, one of the most compelling findings of our study is the reduction in operative time when ICG is used. As detailed in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, ICG NIRF-C also contributed to a significant reduction in operative time, especially in high-risk patients. On average, surgeries in this study lasted 45\u0026thinsp;\u0026plusmn;\u0026thinsp;15 minutes, with 56% of patients with \u003cb\u003eG10 scores\u0026thinsp;\u0026lt;\u0026thinsp;3\u003c/b\u003e completing surgery in less than 45 minutes. However, the impact of ICG is even more pronounced in patients with \u003cb\u003eG10 scores\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/b\u003e, where only 16% of patients had surgeries exceeding 90 minutes (p\u0026thinsp;=\u0026thinsp;0.01). This reduction in operative time has important implications for postoperative outcomes, including a potentially lower risk of complications and improved efficiency in the use of operating room resources, which are critical factors in optimizing surgical workflows. This is in line with Tsutsui et al.\u003csup\u003e15\u003c/sup\u003e, who found that the use of ICG reduced surgery times by improving intraoperative decision-making and dissection efficiency.\u003c/p\u003e\u003cp\u003ePatients with \u003cb\u003eG10 scores\u0026thinsp;\u0026ge;\u0026thinsp;5\u003c/b\u003e, who typically face a 33% conversion rate and longer surgery durations\u003csup\u003e27\u003c/sup\u003e, saw operative times reduced significantly with ICG. Only 7% of these high-risk patients required more than 90 minutes for surgery (p\u0026thinsp;=\u0026thinsp;0.03). These results align with and expand upon the findings from the CholeS Study Group\u003csup\u003e29\u003c/sup\u003e, which demonstrated that preoperative factors could predict longer surgeries. Our study builds on this by showing how the use of ICG mitigates these risks specifically through enhanced intraoperative visualization, resulting in improved outcomes even in high-complexity cases (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe impact of ICG in reducing operative time was also evident in patients classified with higher \u003cb\u003eSurgical Time Score\u003c/b\u003e, a score validated in an independent cohort of 2405 patients and demonstrating good predictive capacity, with an area under the ROC curve of 0.708\u003csup\u003e29\u003c/sup\u003e. According to the CholeS Study Group, surgeries in patients with intermediate or high-risk scores are expected to exceed 90 minutes, but in this study and contrary to what might be expected, none of the high-risk patients had surgeries lasting over 90 minutes, thanks to the use of ICG. Bharamgoudar et al.\u003csup\u003e29\u003c/sup\u003e highlighted similar outcomes, where ICG helped reduce surgical times and improve resource allocation in complex cholecystectomy cases. Additionally, Sugrue et al.\u003csup\u003e26\u003c/sup\u003e demonstrated that accurate intraoperative visualization, especially in cases deemed complex by scores such as G10 and the Surgical Time Score (CholeS Study Group), can significantly reduce operative times, which directly correlates with our findings (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eExpected percentage of candidate interventions for outpatient surgery according to CAAD score\u003c/h2\u003e\u003cp\u003eA CAAD score of ≦\u0026thinsp;5 is associated with 80.8% successful day-case cholecystectomy compared with 19.2% associated with a CAAD score\u0026thinsp;\u0026gt;\u0026thinsp;5 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003csup\u003e28\u003c/sup\u003e. In terms of ambulatory surgery eligibility, 63.6% of our patients had \u003cb\u003eCAAD scores\u0026thinsp;\u0026gt;\u0026thinsp;5\u003c/b\u003e, a group that typically has only a 19.2% chance of successful day-case surgery. Despite this, ICG allowed for the safe discharge of all patients the day after surgery, suggesting that ICG can help expand the eligibility for ambulatory cholecystectomy. In our serie, there were no day-case surgeries but in all patients LC was performed safely with the visualization of CBD in all surgeries and all patients were discharged the next day after surgery without postoperative complications or readmissions. This finding is supported by El-Sharkawy et al.\u003csup\u003e28\u003c/sup\u003e, who demonstrated that the use of ICG in high-risk day-case surgeries can significantly improve outcomes by reducing the incidence of complications that typically necessitate prolonged hospital stays (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of this study demonstrate that ICG NIRF-C significantly enhances biliary anatomy visualization, reduces operative time, and minimizes the need for conversion to open surgery, even in high-risk laparoscopic cholecystectomy cases. By improving intraoperative identification of key biliary structures, ICG facilitates safer dissection, particularly in patients with distorted anatomy, severe inflammation, or high surgical complexity as indicated by CLOC, G10, and Nassar scores. The ability of ICG to optimize intraoperative decision-making likely contributed to the zero-conversion rate observed in this study, despite a high proportion of patients classified as at-risk for conversion.\u003c/p\u003e\u003cp\u003eFurthermore, the reduction in operative time associated with ICG use has both clinical and logistical benefits, lowering exposure to prolonged anesthesia, minimizing intraoperative complications, and improving operating room efficiency. These advantages extend to ambulatory laparoscopic cholecystectomy, where ICG may play a role in expanding patient eligibility for same-day discharge by reducing intraoperative risks and ensuring a safer recovery.\u003c/p\u003e\u003cp\u003eThese findings strongly support the integration of ICG fluorescence cholangiography as a standard tool in laparoscopic cholecystectomy, particularly in complex cases. Future multicentric studies with larger cohorts should further validate these results and explore the potential of ICG to refine risk stratification models and surgical decision-making in hepatobiliary surgery.\u003c/p\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eLimitations of the study\u003c/h2\u003e\u003cp\u003eThis study has several limitations. Firstly, it is a retrospective review based on patients submitted to LC, which increases the possibility of selection bias. Secondly, other important limitations of our study are the sample size and the lack of a control group which would give a higher validity to our conclusions. Moreover, to demonstrate other aims such as a potential reduction in BDIs, a larger sample would be needed. An external validation of the use of ICG in high risk scores would be helpful in order to corroborate the relationships we hypothesize. Furthermore, as a topic for further research, it would be interesting to create a new risk score for conversion to open surgery considering the biliary anatomy identified with ICG NIRF-C.\u003c/p\u003e\u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cem\u003elaparoscopic cholecystectomy (LC), bile duct injury (BDI), indocyanine green (ICG), near-infrared fluorescence cholangiography (NIRF-C), near infrared (NIR), white light (WL), cystic duct (CD), common bile duct (CBD), cystic duct-bile duct junction (CDBDJ), visual analogue scale (VAS), Body Mass Index (BMI), American Society of Anaesthesiologists (ASA).\u003c/em\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe present study has been approved by the Research Committee of the Hospital Universitari Son Espases under reference number CI-344-19. It is registered in the U.S. Clinical Trials and Studies Database (ClinicalTrials.gov) with the identification number NCT04005898.\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAuthor contribution\u0026nbsp;\u003c/strong\u003eThe corresponding author attests that all listed authors meet authorship criteria and that no other meeting the criteria have been omitted.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe manuscript\u0026rsquo;s guarantor affirms that the manuscript is an honest, accurate and transparent account of the study being reported; no important aspects of the study have been omitted and any discrepancies from the study as planned have been explained. Drs. Natalia Pujol- Cano, Francesc Xavier Molina-Romero, El\u0026iacute;as Palma-Zamora, Jaume Bonnin-Pascual, Magdalena Coll-Sastre, Francesc Xavier Gonz\u0026aacute;lez- Argent\u0026eacute; and Jos\u0026eacute; Miguel Mor\u0026oacute;n-Canis have no conflicts of interest or financial ties to disclose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u0026nbsp;\u003c/strong\u003eAll authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePerissat J (1993) Laparoscopic cholecystectomy: the European experience. Am J Surg 165(4):444\u0026ndash;449\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNuzzo G, Giuliante F, Giovannini I, Ardito F, D\u0026rsquo;Acapito F et al (2005) Vel- lone M Bile duct injury during laparoscopic cholecystectomy: results of an Italian national survey on 56 591 cholecystectomies. Arch Surg 140(10):986\u0026ndash;992\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTornqvist B, Stromberg C, Persson G, Nilsson M (2012) Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study. BMJ 345:e6457\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHalbert C, Pagkratis S, Yang J, Meng Z, Altieri MS, Parikh P et al (2016) Beyond the learning curve: incidence of bile duct injuries following laparoscopic cholecystectomy normalize to open in the modern era. Surg Endosc 30(6):2239\u0026ndash;2243\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFlum DR, Dellinger EP, Cheadle A, Chan L, Koepsell T (2003) Intraoperative cholangiography and risk of common bile duct injury during cholecystectomy. JAMA 289(13):1639\u0026ndash;1644\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePesce A, Portale TR, Minutolo V, Scilletta R, Li Destri G, Puleo S (2012) Bile duct injury during laparoscopic cholecystectomy without intraoperative cholangiography: a retrospective study on 1,100 selected patients. Dig Surg 29(4):310\u0026ndash;314\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMachado NO (2011) Biliary complications postlaparoscopic cholecystectomy: mechanism, preventive measures, and approach to management: a review. Diagn Ther Endosc 2011:967017\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKum CK, Eypasch E, Lefering R, Paul A, Neugebauer E, Troidl H (1996) Laparoscopic cholecystectomy for acute cholecystitis: is it really safe? World J Surg 20(1):43\u0026ndash;48\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBooij KA, de Reuver PR, Yap K, van Dieren S, van Delden OM, Rauws EA et al (2015) Morbidity and mortality after minor bile duct injury following laparoscopic cholecystectomy. Endoscopy 47(1):40\u0026ndash;46\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIshizawa T, Bandai Y, Ijichi M, Kaneko J, Hasegawa K, Kokudo N (2010) Fluorescent cholangiography illuminating the biliary tree during laparoscopic cholecystectomy. Br J Surg 97(9):1369\u0026ndash;1377\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchols RM, Bouvy ND, Masclee AA, van Dam RM, Dejong CH, Stassen LP (2013) Fluorescence cholangiography during laparoscopic cholecystectomy: a feasibility study on early biliary tract delineation. Surg Endosc 27(5):1530\u0026ndash;1536\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDip F, LoMenzo E, Sarotto L, Phillips E, Todeschini H, Nahmod M et al (2019) Randomized trial of near-infrared incisionless fluorescent cholangiography. Ann Surg 270(6):992\u0026ndash;999\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCherrick GR, Stein SW, Leevy CM, Davidson CS (1960) Indocyanine green: observations on its physical properties, plasma decay, and hepatic extraction. J Clin Invest 39:592\u0026ndash;600\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZarrinpar A, Dutson EP, Mobley C, Busuttil RW, Lewis CE, Tillou A et al (2016) Intraoperative laparoscopic near-infrared fluorescence cholangiography to facilitate anatomical identification: when to give indocyanine green and how much. Surg Innov 23(4):360\u0026ndash;365\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTsutsui N, Yoshida M, Nakagawa H, Ito E, Iwase R, Suzuki N et al (2018) Optimal timing of preoperative indocyanine green admin- istration for fluorescent cholangiography during laparoscopic cholecystectomy using the PINPOINT(R) Endoscopic Fluorescence Imaging System. Asian J Endosc Surg 11(3):199\u0026ndash;205\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAgnus V, Pesce A, Boni L, Van Den Bos J, Morales-Conde S, Paganini AM et al 2019 Fluorescence-based cholangiography: preliminary results from the IHU-IRCAD-EAES EURO-FIGS registry. Surg Endosc\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNassar AHM, Ashkar KA, Mohamed AY, Hafiz AA (1995) Is laparoscopic cholecystectomy possible without video technology? Minim Invasive Ther Allied Technol 4:63\u0026ndash;65\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDiana M, Soler L, Agnus V, D\u0026rsquo;Urso A et al (2017) Prospective evaluation of precision multimodal gallbladder surgery navigation virtual reality, near-infrared fluorescence, and X-ray-based intraoperative cholangiography. Ann Surg 266:890\u0026ndash;897\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePesce A, Piccolo G, La Greca G, Puleo S (2015) Utility of fluorescent cholangiography during laparoscopic cholecystectomy: a systematic review. World J Gastroenterol 21(25):7877\u0026ndash;7883\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKono Y, Ishizawa T, Tani K, Harada N et al 2015 Techniques of fluorescence cholangiography during laparoscopic cholecystectomy for better delineation of the bile duct anatomy. Medicine; 94(25)\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen Q, Zhou R, Weng J, Lai Y et al 2020 Extrahepatic biliary tract visualization using near-infrared fluorescence imaging with indocyanine green: optimization of dose and dosing time. Surg Endosc\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHiwatashi K, Okumura H, Setoyama T, Ando K, Ogura Y et al 2018 Evaluation of laparoscopic cholecystectomy using indocyanine green cholangiography including cholecystitis. A retrospective study. Medicine; 97(30)\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOsayi S, Wendling M, Drosdeck JM, Chaudhry UI et al (2015) Near-infrared fluorescent cholangiography facilitates identification of biliary anatomy during laparoscopic cholecystectomy. Surg Endosc 29:368\u0026ndash;375\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDindo D et al (2004) Classification of surgical complications. Ann Surg 240(2):205\u0026ndash;213\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStrasberg SM, Hertl M, Soper NJ (1995) An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 180:101\u0026ndash;125\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSugrue M, Coccolini F, Bucholc M, Johnston A, Contributors WSES (2019) Intra-operative gallbladder scoring predicts conversion of laparoscopic to open cholecystectomy: a WSES prospective collaborative study. \u003cem\u003eWorld Journal of Emergency Surgery\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(1), 12\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSutcliffe RP, Hollyman M, Hodson J, Bonney G, Vohra RS, Griffiths EA, Fenwick S, Elmasry M, Nunes Q, Kennedy D, Khan RB, Khan MAS, Magee CJ, Jones SM, Mason D, Parappally CP, Mathur P, Saunders M, Jamel S, Shenoy H (2016) Preoperative risk factors for conversion from laparoscopic to open cholecystectomy: a validated risk score derived from a prospective U.K. database of 8820 patients. HPB: official J Int Hepato Pancreato Biliary Association 18(11):922\u0026ndash;928\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEl-Sharkawy AM, Tewari N, Vohra RS, CholeS Study Group, West Midlands Research Collaborative (2023) Correction: The cholecystectomy as A day case (CAAD) score: A validated score of preoperative predictors of successful day-case cholecystectomy using the CholeS data set. World J Surg 47(4):1082\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBharamgoudar R, Sonsale A, Hodson J, Griffiths E (2018) The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy. Surg Endosc 32(8):3149\u0026ndash;3157\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNassar AHM, Hodson J, Ng HJ, Vohra RS, Katbeh T, Zino S, Griffiths EA (2019) Predicting the difficult laparoscopic cholecystectomy: Development and validation of a pre-operative risk score using an objective operative difficulty grading system. Surg Endosc 33(12):1\u0026ndash;15\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6900172/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6900172/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eLaparoscopic cholecystectomy(LC) is the standard treatment for gallbladder disease. However, complex cases may require conversion to open surgery. Indocyanine green near-infrared fluorescence cholangiography(ICG NIRF-C) enhances biliary visualization, potentially reducing conversion rates, surgical time and complications.This study evaluates ICG\u0026rsquo;s role in improving LC outcomes using five predictive risk scores.\u003c/p\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eForty-four LC patients received a single 0.25 mg intravenous ICG dose during anesthesia induction. Data collected included demographics, biliary visualization before and after dissection, complications, operative time and risk scores.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eICG fluorescence improved biliary visualization: common bile duct(CBD) was identified in 29% of cases before and 100% after dissection. Despite 61.4% of patients having a CLOC score\u0026thinsp;\u0026gt;\u0026thinsp;6 and 43.2% a G10 score\u0026thinsp;\u0026ge;\u0026thinsp;3 no conversions occurred. Only 7% of cases exceeded 90 minutes (p\u0026thinsp;=\u0026thinsp;0.03).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eICG NIRF-C enhances biliary anatomy visualization, reducing conversion rates and operative time, supporting its integration as a standard LC tool.\u003c/p\u003e","manuscriptTitle":"Impact of Indocyanine Green in Laparoscopic Cholecystectomy: Enhancing Safety, Reducing Conversion Rates and Optimizing Operative Time through Predictive Scoring Systems","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-28 15:29:40","doi":"10.21203/rs.3.rs-6900172/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-16T09:15:53+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-14T10:35:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-09T23:56:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"241301208464405346256839143208113733083","date":"2025-07-31T02:03:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"314999916157416506204891736934145907653","date":"2025-07-29T14:46:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204503507115890974174417372103803355726","date":"2025-07-27T17:20:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"200395938009425161623506981602088017486","date":"2025-07-27T17:05:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"24846865743775681083731934143491956983","date":"2025-07-26T13:33:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"61978262887066686797864747862106992106","date":"2025-07-26T13:01:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-24T17:35:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"218534702471461250895258802404747715606","date":"2025-07-24T14:34:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173821340620783645420952889455204128093","date":"2025-07-24T13:02:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-24T12:53:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-19T08:00:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-19T06:58:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"Langenbeck's Archives of Surgery","date":"2025-06-15T20:55:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"1ba3dbc4-c32e-45a4-bc06-d00750787807","owner":[],"postedDate":"July 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T17:07:02+00:00","versionOfRecord":{"articleIdentity":"rs-6900172","link":"https://doi.org/10.1007/s00423-025-03934-y","journal":{"identity":"langenbecks-archives-of-surgery","isVorOnly":false,"title":"Langenbeck's Archives of Surgery"},"publishedOn":"2026-01-14 16:30:31","publishedOnDateReadable":"January 14th, 2026"},"versionCreatedAt":"2025-07-28 15:29:40","video":"","vorDoi":"10.1007/s00423-025-03934-y","vorDoiUrl":"https://doi.org/10.1007/s00423-025-03934-y","workflowStages":[]},"version":"v1","identity":"rs-6900172","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6900172","identity":"rs-6900172","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}