Main text
Biliary fistulas (BFs) after hepatectomy are a challenging complication and are occasionally accompanied by serious conditions such as liver failure or severe infection despite recent improvements in perioperative care and surgical techniques. The bile leak test has been reported to be efficient in detecting bile leakage during surgery1; however, it is not valid for identifying bile leaks that do not involve the common bile duct (e.g., Nagano Type D bile leakage2).
In our institution, indocyanine green (ICG) (10 mg/body) is administered intravenously to determine the hepatic resection area, and the liver is observed with an ICG camera system (Stryker AIM1588, Kalamazoo, MI) after the completion of hepatectomy. Since intravenous ICG is taken up by the hepatocytes and then in bile, this property can be used to identify the bile ducts. In the section plane after hepatectomy, bile leakage could be observed more clearly, compared to naked-eye observation, as an ICG-fluorescence contamination of the gauze (Fig. 1, Supplementary video 1). This allows for the appropriate treatment of intraoperative subclinical bile leakage, thus preventing BF. Further, the method seems useful for the detection of Nagano Type D bile leakage2, which cannot be detected via conventional bile leak tests.