Koo TH, Leong XB, Lee YL, Hayati F, Zakaria MH, Zakaria AD. Transforming biliary surgery: Innovations in fluorescence-guided imaging and indocyanine green application. World J Gastrointest Surg 2025; 17(8): 102921 [DOI: 10.4240/wjgs.v17.i8.102921]
Corresponding Author of This Article
Andee Dzulkarnaen Zakaria, MD, Professor, Department of Surgery, School of Medical Sciences and Hospital Universiti Sains Malaysia, Jalan Raja Perempuan Zainab 2, Kota Bharu 16150, Kelantan, Malaysia. andee@usm.my
Research Domain of This Article
Surgery
Article-Type of This Article
Editorial
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Thai-Hau Koo, Department of Internal Medicine, School of Medical Sciences and Hospital Universiti Sains Malaysia, Kota Bharu 16150, Kelantan, Malaysia
Xue-Bin Leong, Yi-Lin Lee, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, Kubang Kerian 16150, Kelantan, Malaysia
Firdaus Hayati, Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu 88400, Sabah, Malaysia
Mohd Hazeman Zakaria, Department of Radiology, Faculty of Medicine and Health Science, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia
Andee Dzulkarnaen Zakaria, Department of Surgery, School of Medical Sciences and Hospital Universiti Sains Malaysia, Kota Bharu 16150, Kelantan, Malaysia
Author contributions: Koo TH, Hayati F, and Zakaria AD designed the overall concept and outline of the manuscript; Leong XB, Lee YL, and Zakaria MH contributed to the discussion and design of the manuscript; Koo TH, Leong XB, Lee YL, Zakaria MH, and Zakaria AD contributed to the writing and editing of the manuscript, illustrations, and review of the literature; All authors have read and approved the final manuscript.
Conflict-of-interest statement: All the authors report having no relevant conflicts of interest for this article.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Andee Dzulkarnaen Zakaria, MD, Professor, Department of Surgery, School of Medical Sciences and Hospital Universiti Sains Malaysia, Jalan Raja Perempuan Zainab 2, Kota Bharu 16150, Kelantan, Malaysia. andee@usm.my
Received: November 22, 2024 Revised: March 8, 2025 Accepted: April 7, 2025 Published online: August 27, 2025 Processing time: 296 Days and 2.6 Hours
Abstract
In this editorial, we comment on the article by Li et al. We specifically focus on the novel use of multicolor near-infrared fluorescence imaging (MCFI) with indocyanine green in laparoscopic cholecystectomy, which is an innovative approach for enhancing biliary visualization during laparoscopic cholecystectomy. This study also highlighted the limitations of conventional single-color fluorescence imaging (SCFI), which relies solely on a green fluorescence signal, leading to challenges such as visual fatigue and difficulty in distinguishing biliary structures from background hepatic tissue. Given the complex anatomy of the biliary system and the challenges of visual fatigue encountered with SCFI, MCFI addresses these issues by enabling the differentiation of biliary structures by mapping the fluorescence intensity across a unique blue-to-purple color spectrum, thus improving the clarity of anatomical structures and reducing the visual strain for surgeons. We also focus specifically on the complications and cautious usage of indocyanine green in this context, as well as the advantages and disadvantages of MCFI and SCFI. Overall, MCFI represents a significant advancement in fluorescence-guided surgery, with the potential to become a standard imaging modality for safer and more effective laparoscopic procedures.
Core Tip: Multicolor near-infrared fluorescence imaging using indocyanine green has emerged as a transformative tool in laparoscopic cholecystectomy, enhancing the real-time visualization of biliary anatomy and reducing bile duct injuries. This innovative technique improves the identification of critical structures, such as the cystic and common bile ducts even in challenging cases involving inflammation or anatomical variations. By offering superior safety, cost-effectiveness, and the potential for surgical training, indocyanine green fluorescence cholangiography demonstrates advantages over conventional methods. However, challenges such as tissue penetration and workflow integration require further investigation through standard protocols and multicenter trials to establish its role as a standard of care.
