This large national cohort study evaluated whether intraoperative ICG fluorescence cholangiography is associated with reduced common bile duct (CBD) injury in adults undergoing laparoscopic cholecystectomy, using data from the Epic Cosmos dataset across multiple hospitals (2016–2024, n=1,266,024).
After IPTW adjustment, ICG use was associated with a 38% lower rate of CBD injury (0.25% vs 0.40%; RR 0.62, 95% CI 0.49–0.79), 17% fewer subsequent biliary interventions (4.49% vs 5.39%; RR 0.83), 52% lower conversion to open surgery (0.40% vs 0.84%; RR 0.48), and 16% fewer nonbiliary 30-day complications (7.25% vs 8.64%; RR 0.84); all P < .001.
- Observational design with IPTW cannot fully eliminate unmeasured confounding (e.g., surgeon skill, case complexity, institutional protocols). - CBD injury rates are low overall, so absolute risk differences are small despite statistical significance. - Reliance on EHR data (Epic Cosmos) may introduce coding inaccuracies for outcomes and exposures.
Routine use of intraoperative ICG fluorescence cholangiography during laparoscopic cholecystectomy appears to meaningfully reduce CBD injury and related complications — clinicians should consider adopting it as a standard safety adjunct where feasible.
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