Indocyanine green fluorescence cholangiography versus intraoperative cholangiography for laparoscopic cholecystectomy: an updated systematic review and meta-analysis of randomized controlled trials.

Bile duct injury during laparoscopic cholecystectomy is mainly related to misidentification of extrahepatic biliary anatomy. This systematic review and meta-analysis compared indocyanine green fluorescence cholangiography (ICG-FC) with conventional intraoperative X-ray cholangiography (IOC) for biliary visualization, procedural efficiency, technical success, surgeon satisfaction, and perioperative safety. PubMed, Scopus, Web of Science, and CENTRAL were searched without restrictions. Eligible studies were randomized controlled trials comparing ICG-FC with conventional IOC in adults undergoing laparoscopic cholecystectomy. The primary outcome was successful visualization of extrahepatic biliary anatomy. Secondary outcomes included cholangiography failure, cholangiography duration, total operative time, surgeon satisfaction, choledocholithiasis detection, perioperative complications, morbidity, conversion to open surgery, and bile duct injury. Risk of bias was assessed using the Cochrane RoB 2 tool, and random-effects models were applied. Three RCTs including 494 patients were included. Overall biliary visualization did not differ significantly between ICG-FC and IOC (RR 1.02, 95% CI 0.99-1.07; P = 0.22; I2 = 0%), including CBD (RR 1.08, 95% CI 0.99-1.18), cystic duct (RR 1.02, 95% CI 0.96-1.09), critical junction (RR 0.98, 95% CI 0.90-1.07), and CHD visualization (RR 1.01, 95% CI 0.93-1.10). ICG-FC significantly reduced cholangiography failure (RR 0.08, 95% CI 0.01-0.58; P = 0.01) and cholangiography duration (MD - 3.90 min, 95% CI - 5.36 to - 2.44; P < 0.00001). Surgeon usability favored ICG-FC (SMD 0.88, 95% CI 0.09-1.68; P = 0.03), while total operative time (MD - 1.30 min, 95% CI - 6.76 to 4.15; P = 0.64), choledocholithiasis detection (RR 1.29, 95% CI 0.51-3.27; P = 0.59), postoperative complications (RR 0.80, 95% CI 0.22-2.91; P = 0.73), morbidity (RR 1.61, 95% CI 0.43-5.98; P = 0.48), and conversion to open surgery (RR 0.23, 95% CI 0.04-1.36; P = 0.11) were comparable. No bile duct injuries were recorded. ICG-FC provides biliary visualization comparable to IOC while improving technical success and reducing cholangiography duration. Large multicentre randomized controlled trials are required to determine whether these technical advantages reduce bile duct injury.