Gallbladder Volvulus and the Use of Indocyanine Green

Gallbladder Volvulus and the Use of Indocyanine Green | 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 Case Report Gallbladder Volvulus and the Use of Indocyanine Green Benson Law, Chris J. Zhang, Shane Smith This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9205825/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Purpose Gallbladder volvulus is a rare condition that is often difficult to diagnose preoperatively and can present significant intraoperative challenges due to distorted biliary anatomy and possible vascular compromise. This case study describes the use of indocyanine green fluorescence imaging to assist with anatomical visualization and tissue assessment during laparoscopic cholecystectomy. Methods A 65-year-old woman presented with 24 hours of nausea and right upper quadrant pain. Computed tomography and ultrasound imaging suggested acute cholecystitis without gallstones. During the subsequent laparoscopic cholecystectomy, a necrotic gallbladder volvulus was visually identified and detorted. Indocyanine green administered preoperatively enabled intraoperative visualization of the common bile duct, identification of a necrotic cystic duct and thrombosed cystic artery, and confirmation of the critical view of safety. Discussion Indocyanine green can help to visualize biliary anatomy during laparoscopic cholecystectomies, especially in anatomically difficult cases. In gallbladder volvulus, the distorted anatomy makes achieving the critical view of safety challenging and increases the risk of common bile duct injury. Compared with intraoperative cholangiography, indocyanine green provides faster, real-time visualization of biliary structures and may improve intraoperative identification of biliary structures. Conclusion Preoperative administration of indocyanine green can improve intraoperative biliary visualization. This can enable the attainment of the critical view of safety in the context of distorted anatomy caused by the gallbladder volvulus. Gallbladder volvulus Gallbladder torsion Laparoscopic cholecystectomy Indocyanine Green Figures Figure 1 Figure 2 Figure 3 Introduction While acute cholecystitis (AC) is a common urgent presentation in general surgery, a rare but serious mimicker is gallbladder volvulus (GV). With an incidence in the literature of 1 out of 365,000 cases of gallbladder pathology, GV occurs when there is a twisting of the vascular pedicle [1]. It is most often seen in older adults, with a mean age of 77, and presents to a ratio of 4:1 of males to female [2]. Although GV similarly presents with nausea, vomiting, and right upper quadrant pain, it necessitates a much more urgent laparoscopic cholecystectomy (LC) than AC. Failure to act quickly can lead to worsening obstruction of arterial flow and biliary drainage, leading to edema, ischemia, necrosis, and subsequent perforation and peritonitis. GV has been thought to be due to an elongated mesentery that allows it to hang freely from the inferior surface of the liver [3]. This mesentery may envelop the entire gallbladder and cystic duct or involve the cystic duct alone [1]. Age-related atrophy of surrounding tissues and loss of supporting fat may increase visceral mobility, allowing the gallbladder to twist on its pedicle and occlude the cystic artery and cystic vein, ultimately leading to infarction of the gallbladder [1]. GV is difficult to diagnose and can also be challenging to manage perioperatively. Radiographically, GV has been reported to present on computed tomography (CT) as gallbladder distension, the presence of a “beak and swirl” sign, and the gallbladder lying in an atypical horizontal position [4]. Elements of these findings have been incorporated into proposed diagnostic criteria by Kitagawa et al., which include four features: fluid collection in the gallbladder fossa, a shift in the gallbladder axis from vertical to horizontal, a hyperenhancing cystic duct located to the right of the gallbladder, and imaging features consistent with acute inflammation of the gallbladder wall [5]. Despite these proposals, the criteria have not been validated as specific diagnostic markers, likely due to the rarity of the condition. In addition to non-specific imaging findings and a clinical presentation that may mimic AC, intraoperative management can also be challenging. In GV, biliary anatomy may be distorted, and vascular compromise can make it difficult to clearly delineate the extent of non-viable tissue. To address these challenges, adjunct intraoperative techniques may be used to assist the surgeon. This case study illustrates the use of indocyanine green (ICG), a fluorescent dye used to visualize biliary anatomy, during the intraoperative management of GV. Its use helped facilitate identification of the biliary structures and achieve the critical view of safety during a LC. Case Presentation A 65-year-old otherwise healthy female presented to the emergency department with a 24-hour history of nausea, right upper quadrant pain, and decreased oral intake. Her past medical was notable for longstanding irritable bowel syndrome with constipation and a history of a difficult colonoscopy. Her family history was unremarkable, with a surgical history notable for a prior tubal ligation. Imaging was obtained, beginning with an abdominal pelvic CT scan followed by an abdominal ultrasound (US). The CT demonstrated equivocal findings concerning for AC, showing a distended gallbladder with mural wall edema and thickening, as well as pericholecystic fluid. Of note, a prior CT from five years prior was unable to visualize the gallbladder and very redundant colon was also appreciated. No gallstones were identified. The scan also demonstrated mild dilation of the intrahepatic and extrahepatic bile ducts and mild prominence of the pancreatic duct, without evidence of choledocholithiasis or an obstructing lesion. Subsequent ultrasound was performed to better evaluate the gallbladder wall thickening and pericholecystic fluid. Findings remained consistent with AC, demonstrating a thickened and edematous gallbladder wall without evidence of rupture. Given the anticipated difficulty of the gallbladder dissection and the biliary duct dilation noted on imaging, along with the CT finding from give years ago demonstrating abnormal anatomy, 2.5 mg of ICG was administered preoperatively. On laparoscopy, unusual anatomy was noted. The patient was found to have a very loose mesentery and a redundant colon. A large necrotic, cystic structure in the right upper quadrant was identified to be the gallbladder with a long mesentery that had twisted upon itself, consistent with GV (Fig. 1 ). Adhesions involving the omentum and mesentery were taken down and detorsion of the gallbladder allowed it to return to a more typical anatomical orientation, with the fundus positioned superiorly and Hartmann’s pouch directed inferiorly. Thereafter, the SPY Portable Handheld Imager (SPY-PHI) was activated prior to further dissection to minimize the risk of inadvertent injury. Using the SPY-PHI in conjunction with ICG, we were able to clearly visualize the common bile duct (CBD) as it entered the duodenum, as well as a branch extending toward the gallbladder. This branch abruptly lost fluorescence as it approached the gallbladder. This was consistent with a necrotic cystic duct. Using this as an anatomical landmark, we dissected the triangle of calot and encountered a thrombosed cystic artery. The critical view of safety was achieved and confirmed with SPY-PHI (Figure 2), The structures were taken and the gallbladder was removed without spillage of bile or bleeding. With the gallbladder removed, we again confirmed with SPY-PHY the anatomy of the CBD and the cystic duct (Figure 3). Discussion GV is a rare presentation among gallbladder pathologies. Although clinical findings combined with imaging may help guide clinicians toward the correct diagnosis, they are often insufficient, and this potentially life-threatening condition can be missed [4]. Several imaging features have been described as previously mentioned, including the “beak” and “swirl” signs on CT. The “beak” sign represents the transition from the distended gallbladder lumen to the point of torsion, while the “swirl” sign reflects twisting of the vascular pedicle with surrounding fat and edema [4]. CT may also demonstrate diffuse gallbladder wall thickening, pericholecystic fluid, and poor delineation of the gallbladder wall [6–7]. Similarly, US may show a distended, “floating”, acalculous gallbladder [2, 8]. Despite a growing body of literature describing radiological findings associated with GV, no imaging modality can definitively establish the diagnosis. As such, preoperative diagnosis remains uncommon, with reported rates improving only from approximately 10% to 26% [2]. In this case study, many of the aforementioned radiological findings including a distended gallbladder with mural wall edema and thickening, pericholecystic fluid, and an acalculous gallbladder, were also seen. Given the anticipated difficulty of the dissection and abnormal imaging, 2.5 mg of ICG was administered preoperatively to aid in operative visualization. Originally developed by Kodak for photographic image processing, ICG has since been widely adopted in surgery. Its applications now include tumor and lymph node identification, assessment of bowel perfusion in colorectal surgery, and visualization of biliary anatomy during LCs to help prevent injury to the CBD [9–13]. Bile duct injuries occur in approximately 1.2–1.6% of LCs, and additional caution is warranted when managing GV, where distorted anatomy can make achieving the critical view of safety particularly challenging [14]. General surgical principles in GV include decompression of the gallbladder, detorsion, identification of Calot’s triangle, and subsequent attainment of the critical view of safety [15]. The use of intraoperative cholangiogram (IOC) has also been proposed to help delineate biliary anatomy and identify variations, particularly as GV may cause stretching or distortion of the common bile duct [16]. However, IOC is associated with increased operative time, cost, and radiation exposure [17]. In contrast to IOC, ICG fluorescence imaging provides rapid, real-time visualization of biliary structures and has been shown to improve identification of biliary anatomy [17]. This case highlights how preoperative administration of ICG in suspected GV may facilitate intraoperative visualization of biliary anatomy and help reduce the risk of bile duct injury. Conclusion In summary, GV is a rare but life-threatening condition that can mimic AC, making preoperative diagnosis challenging. In this case, GV was not identified during preoperative imaging but only during the LC. However, preoperative administration of ICG facilitated intraoperative visualization of the CBD and cystic structures. This improved delineation of biliary anatomy, allowing safe achievement of the critical view of safety and completion of the procedure without bile duct injury despite the distorted anatomy caused by the volvulus. Declarations Funding and Competing interests The authors have no relevant financial or non-financial interests to disclose. Funding No funds, grants, or other support was received. Data Availability All relevant clinical data are included in the manuscript. Additional de-identified data may be provided upon request. Acknowledgements The authors have no acknowledgements. Consent for Publication Informed consent was obtained from the patient for treatment and inclusion in this case report and accompanying images. Ethical Approval This is a single case report exempt from ethical review as per institutional policy. References Kashyap S, Mathew G, Abdul W, Patel PJ. Gallbladder Volvulus. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2026 Mar 8]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557752/ Reilly DJ, Kalogeropoulos G, Thiruchelvam D. Torsion of the gallbladder: a systematic review. HPB [Internet]. 2012 Jul 3;14(10):669–72. Available from: https://doi.org/10.1111/j.1477-2574.2012.00513.x Yeh H, Weiss MF, Gerson CD. Torsion of the gallbladder: The ultrasonographic features. Journal of Clinical Ultrasound [Internet]. 1989 Feb 1;17(2):123–5. Available from: https://doi.org/10.1002/jcu.1870170211 Layton B, Rudralingam V, Lamb R. Gallbladder volvulus: it’s a small whirl. BJR|Case Reports [Internet]. 2016 Feb 10;2(3):20150360. Available from: https://doi.org/10.1259/bjrcr.20150360 Kitagawa H, Nakada K, Enami T, Yamaguchi T, Kawaguchi F, Nakada M, et al. Two cases of torsion of the gallbladder diagnosed preoperatively. Journal of Pediatric Surgery [Internet]. 1997 Nov 1;32(11):1567–9. Available from: https://doi.org/10.1016/s0022-3468(97)90454-1 Keeratibharat N, Chansangrat J. An Unusual Presentation of Acute Cholecystitis due to a Gallbladder Volvulus in a Young Female: A Case Report and Review of the Literature. Cureus [Internet]. 2022 Jan 15;14(1):e21275. Available from: https://doi.org/10.7759/cureus.21275 Vo NT, Le VT, Nguyen QV. Gallbladder volvulus misdiagnosed as acute acalculous cholecystitis: A case report. International Journal of Surgery Case Reports [Internet]. 2024 Jun 27;121:109955. Available from: https://doi.org/10.1016/j.ijscr.2024.109955 Nakao A, Matsuda T, Funabiki S, Mori T, Koguchi K, Iwado T, et al. Gallbladder torsion: case report and review of 245 cases reported in the Japanese literature. Journal of Hepato-Biliary-Pancreatic Surgery [Internet]. 1999 Dec 20;6(4):418–21. Available from: https://doi.org/10.1007/s005340050143 DeLong JC, Chakedis JM, Hosseini A, Kelly KJ, Horgan S, Bouvet M. Indocyanine green (ICG) fluorescence‐guided laparoscopic adrenalectomy. Journal of Surgical Oncology [Internet]. 2015 Sep 29;112(6):650–3. Available from: https://doi.org/10.1002/jso.24057 Ohdaira H, Yoshida M, Okada S, Tsutsui N, Kitajima M, Suzuki Y. New method of indocyanine green fluorescence sentinel node mapping for early gastric cancer. Annals of Medicine and Surgery [Internet]. 2017 Jun 27;20:61–5. Available from: https://doi.org/10.1016/j.amsu.2017.06.019 Baiocchi GL, Diana M, Boni L. Indocyanine green-based fluorescence imaging in visceral and hepatobiliary and pancreatic surgery: State of the art and future directions. World Journal of Gastroenterology [Internet]. 2018 Jul 19;24(27):2921–30. Available from: https://doi.org/10.3748/wjg.v24.i27.2921 Wada T, Kawada K, Takahashi R, Yoshitomi M, Hida K, Hasegawa S, et al. ICG fluorescence imaging for quantitative evaluation of colonic perfusion in laparoscopic colorectal surgery. Surgical Endoscopy [Internet]. 2017 Mar 9;31(10):4184–93. Available from: https://doi.org/10.1007/s00464-017-5475-3 Ambe PC, Plambeck J, Fernandez-Jesberg V, Zarras K. The role of indocyanine green fluoroscopy for intraoperative bile duct visualization during laparoscopic cholecystectomy: an observational cohort study in 70 patients. Patient Safety in Surgery [Internet]. 2019 Jan 12;13(1):2. Available from: https://doi.org/10.1186/s13037-019-0182-8 Ludwig K, Bernhardt J, Lorenz D. Value and Consequences of routine intraoperative cholangiography during cholecystectomy. Surgical Laparoscopy Endoscopy & Percutaneous Techniques [Internet]. 2002 Jun 1;12(3):154–9. Available from: https://doi.org/10.1097/00129689-200206000-00003 Wong M, Pillai S. Gallbladder torsion. CRSLS Journal of the Society of Laparoscopic and Robotic Surgeons [Internet]. 2016 Nov 10;20(4). Available from: https://doi.org/10.4293/crsls.2016.00079 Christoudias GC. Gallbladder volvulus with gangrene. Case report and review of the literature. PubMed [Internet]. 1999 Feb 10;1(2):167–70. Available from: https://pubmed.ncbi.nlm.nih.gov/9876667 Osayi SN, Wendling MR, Drosdeck JM, Chaudhry UI, Perry KA, Noria SF, et al. Near-infrared fluorescent cholangiography facilitates identification of biliary anatomy during laparoscopic cholecystectomy. Surgical Endoscopy [Internet]. 2014 Jul 2;29(2):368–75. Available from: https://doi.org/10.1007/s00464-014-3677-5 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 04 Apr, 2026 Reviews received at journal 31 Mar, 2026 Reviewers agreed at journal 29 Mar, 2026 Reviewers invited by journal 28 Mar, 2026 Editor assigned by journal 24 Mar, 2026 Submission checks completed at journal 24 Mar, 2026 First submitted to journal 23 Mar, 2026 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-9205825","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":616761756,"identity":"0d925110-20fa-44d4-b8b3-dca21c3c0a7b","order_by":0,"name":"Benson Law","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIie3PMYvCMBTA8VcepMsT14hf4h2BeFI/TEXoLR432s1CoY6uV/wSgl+gR1bno9JJDm52kh4caMBNJOjmkD8kWfIjLwA+3xPGod0OPJov7SnvIwgQfKZJUGaPEKStCdbVvWSA+Cs7BaL6Nl+7Fsx4Cbg/uMgwF1r2CiF0k0wisqTMhHI+xwZ0/VIQ6Waq+wDmfV2Re0I24bEeF1Kq1cex114Itm5Cuq62zNyfCkkXIpyvDHOa/WVpHMsmURHx27y0v3t1kUG42Kh/PsXd1WS/a9NIdcP8p3aR6zntwgfu+3w+n+92ZwLuRq6lupBVAAAAAElFTkSuQmCC","orcid":"","institution":"Western University","correspondingAuthor":true,"prefix":"","firstName":"Benson","middleName":"","lastName":"Law","suffix":""},{"id":616761758,"identity":"0d0f1092-7b6f-4c9b-8d3c-03a398f680f8","order_by":1,"name":"Chris J. Zhang","email":"","orcid":"","institution":"Western University","correspondingAuthor":false,"prefix":"","firstName":"Chris","middleName":"J.","lastName":"Zhang","suffix":""},{"id":616761759,"identity":"059fec79-d34b-4338-959d-c4fc71efc747","order_by":2,"name":"Shane Smith","email":"","orcid":"","institution":"Western University","correspondingAuthor":false,"prefix":"","firstName":"Shane","middleName":"","lastName":"Smith","suffix":""}],"badges":[],"createdAt":"2026-03-24 02:40:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9205825/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9205825/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106092316,"identity":"22ee0c5d-610a-4d5c-a07e-e1491b55aaac","added_by":"auto","created_at":"2026-04-03 11:18:52","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":247660,"visible":true,"origin":"","legend":"\u003cp\u003eOn laparoscopy, a necrotic gallbladder without perforation was found, volvulized 360 degrees clockwise upon a redundant mesentery.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9205825/v1/50a93192401409ff528a89d8.jpg"},{"id":106092318,"identity":"f2f99d9c-a6e2-4826-ad5e-0c3ce92dc681","added_by":"auto","created_at":"2026-04-03 11:18:52","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":329923,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative view of gallbladder de-torted, with a critical view of safety achieved. Intraoperative ICG was used to delineate the anatomy and visualize the cystic duct and common bile duct. The proximal cystic duct (a) is seen under ICG fluorescence. The more distal cystic duct (necrotic) was not fluorescent.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9205825/v1/158c00e5d72eea6f3f96b87d.jpg"},{"id":106723438,"identity":"eecd4087-315e-42e9-b24b-74f5041e595b","added_by":"auto","created_at":"2026-04-12 17:43:02","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":262252,"visible":true,"origin":"","legend":"\u003cp\u003eBiliary anatomy post cholecystectomy with ICG. Cystic duct (a) and common bile duct (b) were clearly delineated by ICG. [CZ1]\u003c/p\u003e\n\u003cp\u003e[CZ1]In the original file I sent I had labeled the anatomy with A and B\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9205825/v1/f15eb589063ffc73f83816aa.jpg"},{"id":106723441,"identity":"c2094d70-93d9-42bb-b9b5-a84260bd771e","added_by":"auto","created_at":"2026-04-12 17:43:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1136798,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9205825/v1/f7d28892-ddac-4550-a945-ff32810e6884.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Gallbladder Volvulus and the Use of Indocyanine Green","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWhile acute cholecystitis (AC) is a common urgent presentation in general surgery, a rare but serious mimicker is gallbladder volvulus (GV). With an incidence in the literature of 1 out of 365,000 cases of gallbladder pathology, GV occurs when there is a twisting of the vascular pedicle [1]. It is most often seen in older adults, with a mean age of 77, and presents to a ratio of 4:1 of males to female [2]. Although GV similarly presents with nausea, vomiting, and right upper quadrant pain, it necessitates a much more urgent laparoscopic cholecystectomy (LC) than AC. Failure to act quickly can lead to worsening obstruction of arterial flow and biliary drainage, leading to edema, ischemia, necrosis, and subsequent perforation and peritonitis.\u003c/p\u003e \u003cp\u003eGV has been thought to be due to an elongated mesentery that allows it to hang freely from the inferior surface of the liver [3]. This mesentery may envelop the entire gallbladder and cystic duct or involve the cystic duct alone [1]. Age-related atrophy of surrounding tissues and loss of supporting fat may increase visceral mobility, allowing the gallbladder to twist on its pedicle and occlude the cystic artery and cystic vein, ultimately leading to infarction of the gallbladder [1].\u003c/p\u003e \u003cp\u003eGV is difficult to diagnose and can also be challenging to manage perioperatively. Radiographically, GV has been reported to present on computed tomography (CT) as gallbladder distension, the presence of a \u0026ldquo;beak and swirl\u0026rdquo; sign, and the gallbladder lying in an atypical horizontal position [4]. Elements of these findings have been incorporated into proposed diagnostic criteria by Kitagawa et al., which include four features: fluid collection in the gallbladder fossa, a shift in the gallbladder axis from vertical to horizontal, a hyperenhancing cystic duct located to the right of the gallbladder, and imaging features consistent with acute inflammation of the gallbladder wall [5]. Despite these proposals, the criteria have not been validated as specific diagnostic markers, likely due to the rarity of the condition.\u003c/p\u003e \u003cp\u003eIn addition to non-specific imaging findings and a clinical presentation that may mimic AC, intraoperative management can also be challenging. In GV, biliary anatomy may be distorted, and vascular compromise can make it difficult to clearly delineate the extent of non-viable tissue. To address these challenges, adjunct intraoperative techniques may be used to assist the surgeon. This case study illustrates the use of indocyanine green (ICG), a fluorescent dye used to visualize biliary anatomy, during the intraoperative management of GV. Its use helped facilitate identification of the biliary structures and achieve the critical view of safety during a LC.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 65-year-old otherwise healthy female presented to the emergency department with a 24-hour history of nausea, right upper quadrant pain, and decreased oral intake. Her past medical was notable for longstanding irritable bowel syndrome with constipation and a history of a difficult colonoscopy. Her family history was unremarkable, with a surgical history notable for a prior tubal ligation. Imaging was obtained, beginning with an abdominal pelvic CT scan followed by an abdominal ultrasound (US). The CT demonstrated equivocal findings concerning for AC, showing a distended gallbladder with mural wall edema and thickening, as well as pericholecystic fluid. Of note, a prior CT from five years prior was unable to visualize the gallbladder and very redundant colon was also appreciated. No gallstones were identified. The scan also demonstrated mild dilation of the intrahepatic and extrahepatic bile ducts and mild prominence of the pancreatic duct, without evidence of choledocholithiasis or an obstructing lesion. Subsequent ultrasound was performed to better evaluate the gallbladder wall thickening and pericholecystic fluid. Findings remained consistent with AC, demonstrating a thickened and edematous gallbladder wall without evidence of rupture. Given the anticipated difficulty of the gallbladder dissection and the biliary duct dilation noted on imaging, along with the CT finding from give years ago demonstrating abnormal anatomy, 2.5 mg of ICG was administered preoperatively.\u003c/p\u003e \u003cp\u003eOn laparoscopy, unusual anatomy was noted. The patient was found to have a very loose mesentery and a redundant colon. A large necrotic, cystic structure in the right upper quadrant was identified to be the gallbladder with a long mesentery that had twisted upon itself, consistent with GV (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Adhesions involving the omentum and mesentery were taken down and detorsion of the gallbladder allowed it to return to a more typical anatomical orientation, with the fundus positioned superiorly and Hartmann\u0026rsquo;s pouch directed inferiorly.\u003c/p\u003e \u003cp\u003eThereafter, the SPY Portable Handheld Imager (SPY-PHI) was activated prior to further dissection to minimize the risk of inadvertent injury. Using the SPY-PHI in conjunction with ICG, we were able to clearly visualize the common bile duct (CBD) as it entered the duodenum, as well as a branch extending toward the gallbladder. This branch abruptly lost fluorescence as it approached the gallbladder. This was consistent with a necrotic cystic duct. \u0026nbsp;Using this as an anatomical landmark, we dissected the triangle of calot and encountered a thrombosed cystic artery. \u0026nbsp;The critical view of safety was achieved and confirmed with SPY-PHI (Figure 2), The structures were taken and the gallbladder was removed without spillage of bile or bleeding. \u0026nbsp;With the gallbladder removed, we again confirmed with SPY-PHY the anatomy of the CBD and the cystic duct (Figure 3). \u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eGV is a rare presentation among gallbladder pathologies. Although clinical findings combined with imaging may help guide clinicians toward the correct diagnosis, they are often insufficient, and this potentially life-threatening condition can be missed [4]. Several imaging features have been described as previously mentioned, including the \u0026ldquo;beak\u0026rdquo; and \u0026ldquo;swirl\u0026rdquo; signs on CT. The \u0026ldquo;beak\u0026rdquo; sign represents the transition from the distended gallbladder lumen to the point of torsion, while the \u0026ldquo;swirl\u0026rdquo; sign reflects twisting of the vascular pedicle with surrounding fat and edema [4]. CT may also demonstrate diffuse gallbladder wall thickening, pericholecystic fluid, and poor delineation of the gallbladder wall [6\u0026ndash;7]. Similarly, US may show a distended, \u0026ldquo;floating\u0026rdquo;, acalculous gallbladder [2, 8]. Despite a growing body of literature describing radiological findings associated with GV, no imaging modality can definitively establish the diagnosis. As such, preoperative diagnosis remains uncommon, with reported rates improving only from approximately 10% to 26% [2].\u003c/p\u003e \u003cp\u003eIn this case study, many of the aforementioned radiological findings including a distended gallbladder with mural wall edema and thickening, pericholecystic fluid, and an acalculous gallbladder, were also seen. Given the anticipated difficulty of the dissection and abnormal imaging, 2.5 mg of ICG was administered preoperatively to aid in operative visualization.\u003c/p\u003e \u003cp\u003eOriginally developed by Kodak for photographic image processing, ICG has since been widely adopted in surgery. Its applications now include tumor and lymph node identification, assessment of bowel perfusion in colorectal surgery, and visualization of biliary anatomy during LCs to help prevent injury to the CBD [9\u0026ndash;13]. Bile duct injuries occur in approximately 1.2\u0026ndash;1.6% of LCs, and additional caution is warranted when managing GV, where distorted anatomy can make achieving the critical view of safety particularly challenging [14]. General surgical principles in GV include decompression of the gallbladder, detorsion, identification of Calot\u0026rsquo;s triangle, and subsequent attainment of the critical view of safety [15]. The use of intraoperative cholangiogram (IOC) has also been proposed to help delineate biliary anatomy and identify variations, particularly as GV may cause stretching or distortion of the common bile duct [16]. However, IOC is associated with increased operative time, cost, and radiation exposure [17]. In contrast to IOC, ICG fluorescence imaging provides rapid, real-time visualization of biliary structures and has been shown to improve identification of biliary anatomy [17]. This case highlights how preoperative administration of ICG in suspected GV may facilitate intraoperative visualization of biliary anatomy and help reduce the risk of bile duct injury.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, GV is a rare but life-threatening condition that can mimic AC, making preoperative diagnosis challenging. In this case, GV was not identified during preoperative imaging but only during the LC. However, preoperative administration of ICG facilitated intraoperative visualization of the CBD and cystic structures. This improved delineation of biliary anatomy, allowing safe achievement of the critical view of safety and completion of the procedure without bile duct injury despite the distorted anatomy caused by the volvulus.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding and Competing interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funds, grants, or other support was received.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll relevant clinical data are included in the manuscript. Additional de-identified data may be provided upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no acknowledgements.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from the patient for treatment and inclusion in this case report and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is a single case report exempt from ethical review as per institutional policy.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKashyap S, Mathew G, Abdul W, Patel PJ. Gallbladder Volvulus. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2026 Mar 8]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557752/\u003c/li\u003e\n\u003cli\u003eReilly DJ, Kalogeropoulos G, Thiruchelvam D. Torsion of the gallbladder: a systematic review. HPB [Internet]. 2012 Jul 3;14(10):669–72. Available from: https://doi.org/10.1111/j.1477-2574.2012.00513.x\u003c/li\u003e\n\u003cli\u003eYeh H, Weiss MF, Gerson CD. Torsion of the gallbladder: The ultrasonographic features. Journal of Clinical Ultrasound [Internet]. 1989 Feb 1;17(2):123–5. Available from: https://doi.org/10.1002/jcu.1870170211\u003c/li\u003e\n\u003cli\u003eLayton B, Rudralingam V, Lamb R. Gallbladder volvulus: it’s a small whirl. BJR|Case Reports [Internet]. 2016 Feb 10;2(3):20150360. Available from: https://doi.org/10.1259/bjrcr.20150360\u003c/li\u003e\n\u003cli\u003eKitagawa H, Nakada K, Enami T, Yamaguchi T, Kawaguchi F, Nakada M, et al. Two cases of torsion of the gallbladder diagnosed preoperatively. Journal of Pediatric Surgery [Internet]. 1997 Nov 1;32(11):1567–9. Available from: https://doi.org/10.1016/s0022-3468(97)90454-1\u003c/li\u003e\n\u003cli\u003eKeeratibharat N, Chansangrat J. An Unusual Presentation of Acute Cholecystitis due to a Gallbladder Volvulus in a Young Female: A Case Report and Review of the Literature. Cureus [Internet]. 2022 Jan 15;14(1):e21275. Available from: https://doi.org/10.7759/cureus.21275\u003c/li\u003e\n\u003cli\u003eVo NT, Le VT, Nguyen QV. Gallbladder volvulus misdiagnosed as acute acalculous cholecystitis: A case report. International Journal of Surgery Case Reports [Internet]. 2024 Jun 27;121:109955. Available from: https://doi.org/10.1016/j.ijscr.2024.109955\u003c/li\u003e\n\u003cli\u003eNakao A, Matsuda T, Funabiki S, Mori T, Koguchi K, Iwado T, et al. Gallbladder torsion: case report and review of 245 cases reported in the Japanese literature. Journal of Hepato-Biliary-Pancreatic Surgery [Internet]. 1999 Dec 20;6(4):418–21. 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Available from: https://doi.org/10.1007/s00464-014-3677-5\u003c/li\u003e\n\u003c/ol\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":"innovative-surgical-trends","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Innovative Surgical Trends](https://link.springer.com/journal/44414)","snPcode":"44414","submissionUrl":"https://submission.springernature.com/new-submission/44414/3?","title":"Innovative Surgical Trends","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Gallbladder volvulus, Gallbladder torsion, Laparoscopic cholecystectomy, Indocyanine Green","lastPublishedDoi":"10.21203/rs.3.rs-9205825/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9205825/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eGallbladder volvulus is a rare condition that is often difficult to diagnose preoperatively and can present significant intraoperative challenges due to distorted biliary anatomy and possible vascular compromise. This case study describes the use of indocyanine green fluorescence imaging to assist with anatomical visualization and tissue assessment during laparoscopic cholecystectomy.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA 65-year-old woman presented with 24 hours of nausea and right upper quadrant pain. Computed tomography and ultrasound imaging suggested acute cholecystitis without gallstones. During the subsequent laparoscopic cholecystectomy, a necrotic gallbladder volvulus was visually identified and detorted. Indocyanine green administered preoperatively enabled intraoperative visualization of the common bile duct, identification of a necrotic cystic duct and thrombosed cystic artery, and confirmation of the critical view of safety.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e \u003cp\u003eIndocyanine green can help to visualize biliary anatomy during laparoscopic cholecystectomies, especially in anatomically difficult cases. In gallbladder volvulus, the distorted anatomy makes achieving the critical view of safety challenging and increases the risk of common bile duct injury. Compared with intraoperative cholangiography, indocyanine green provides faster, real-time visualization of biliary structures and may improve intraoperative identification of biliary structures.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePreoperative administration of indocyanine green can improve intraoperative biliary visualization. This can enable the attainment of the critical view of safety in the context of distorted anatomy caused by the gallbladder volvulus.\u003c/p\u003e","manuscriptTitle":"Gallbladder Volvulus and the Use of Indocyanine Green","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-03 11:18:43","doi":"10.21203/rs.3.rs-9205825/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-04T16:13:25+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-01T03:46:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"18546294782671885765456438886486997110","date":"2026-03-29T13:04:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-28T16:51:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-24T12:03:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-24T12:03:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"Innovative Surgical Trends","date":"2026-03-24T02:22:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"innovative-surgical-trends","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Innovative Surgical Trends](https://link.springer.com/journal/44414)","snPcode":"44414","submissionUrl":"https://submission.springernature.com/new-submission/44414/3?","title":"Innovative Surgical Trends","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9a2724de-61a3-42a8-a64b-0604dc62c3da","owner":[],"postedDate":"April 3rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-10T18:39:15+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-03 11:18:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9205825","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9205825","identity":"rs-9205825","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}