Laparoscopic cholecystectomy is the most commonly performed minimal access surgery by general surgeons. Stump cholecystitis is managed by completion cholecystectomy, in which the gall bladder remnant is removed either laparoscopically or using an open technique. In the past, due to the fear of dense adhesions and anatomic distortions, the open method was preferred by many surgeons, but now a laparoscopic approach is also considered to be safe in experienced hands.[12] Gall bladder or cystic duct remnants are amongst the many causes of post-cholecystectomy syndrome.[23]

The incidence of stump cholecystitis is around 5%,[3] it occurs more commonly in middle-aged patients and women and patients’ complaints tend to be similar to those that warranted cholecystectomy in the past.[4]

In 1947, Womack and Crider[5] first described “post cholecystectomy syndrome”, in which patients persist to have their symptoms post cholecystectomy , the incidence being around 10-15%.

Achieving a critical view of safety during surgery makes this procedure safer; however, in cases of emergency and acute cholecystitis, the inflammation around Calot’s triangle makes it difficult to do so. One of the backout options in such scenarios is to perform subtotal cholecystectomy, which effectively avoids bile duct injury.[6]

The various methods that have been described in the literature to perform subtotal cholecystectomy can be broadly divided into fenestrating and reconstituting types.[7] In a study by van Dijk et al.,[8] the fenestrating type of subtotal cholecystectomy was associated with a lower incidence of recurrent biliary events but a higher incidence of bile leaks.

Many patients are treated conservatively initially, without any investigations performed, as most surgeons usually do not consider the gall bladder to be a cause of symptoms post-cholecystectomy. MRCP is the imaging modality of choice in such scenarios, with an accuracy of 92%, while abdominal USG had an accuracy of only 60% in a study by Palanivelu et al.[9]

The first reported case of laparoscopic completion cholecystectomy was described by Gurel et al.[10] in 1995.

Spy fluorescence imaging technology uses a laser-generated infrared light, with ICG as the imaging agent. ICG has a well-established safety profile and, following injection, binds to plasma proteins in the blood before eventually being processed in the liver and excreted in bile. The laser light source illuminates the surgical field with white light and low-intensity, invisible, infrared light, causing the ICG to fluoresce.[11] We have previously published a study on the use of ICG in laparoscopic cholecystectomy, which allowed successful visualisation of at least one biliary structure in 100% of the cases.[12] Our protocol is to give ICG 120 min before surgery, unlike in previous studies.[12]

The use of ICG is known to improve the identification of the biliary tree anatomy, facilitating Calot’s triangle dissection and shortening surgery, thereby reducing the risk of bile duct injuries and making laparoscopic cholecystectomy safer.[13] ICG use is also known to decrease the conversion rate of laparoscopic to open cholecystectomy.[14] According to one study, the overall conversion rate was 0.52% in 2490 patients in whom ICG was used in laparoscopic cholecystectomy and it was 2.52% in the group where laparoscopic cholecystectomy was performed without ICG.[15] Even the incidence of bile duct injuries was lower with ICG use (being 0.12% in the ICG group vs. 1.31% in the non-ICG group).[15] According to a study by Yoshiya et al.,[16] the operative time was significantly lower with ICG use, with a lower conversion rate to open cholecystectomy.

We have previously published our results of nine redo cholecystectomies, of which eight underwent laparoscopic completion cholecystectomy (without the use of ICG), and one conversion was done due to excessive adhesions. The mean operating time for the laparoscopic procedure was 90 min.[17] The mean operating time in our study, with the use of ICG and near-infrared imaging, was 80 min, as opposed to 90 min without ICG use, and all the cases were completed laparoscopically.

A report of two cases published in 2021 described administering 0.25 mg/kg ICG intravenously 16 h before surgery in a case report published in 2021, and it was possible to visualise the biliary anatomy in one case, while accidental duodenal perforation occurred in the other case. Nonetheless, both completion cholecystectomies were completed laparoscopically, with the operating time being 114 min and 280 min, respectively.[18]

In another case report of a robotic completion cholecystectomy, 5 mg of ICG was injected intravenously after the induction of general anaesthesia to visualise the biliary ducts, and an additional 2.5 mg of ICG was injected to confirm the right hepatic artery and remnant cystic artery; the operating time was 95 min.[19]

The use of ICG in our study helped us in delineating the anatomy of the biliary tract and identifying the gall bladder remnant and the cystic duct.