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Page 10 of 13 Zhu et al. Mini-invasive Surg 2023;7:12 https://dx.doi.org/10.20517/2574-1225.2022.117
Figure 16. Fusion of gallbladder to duodenal wall.
Figure 17. Take off of the cystic duct and pulsatile cystic artery were observed using (A) white light illumination and (B) ICG
cholangiography.
Figure 18. Confirmation of closure of the cholecystoduodenal fistula. (A) Intraoperative cholangiogram showed no leakage of bile from
the duodenum; (B and C) ICG was used to confirm the absence of bile leakage accumulation in the operative field from the GB mucosa
patch (black arrows) on the duodenum.
During RAL cholecystectomy, a knuckle of the duodenum was fused to the gallbladder, as expected, with
the stellate-shaped clip’s effect visible on the duodenal wall without exposed metal [Figure 16]. To avoid
duodenal injury, a divot of the gallbladder was excised and left on the duodenum. The gallbladder defect
was sutured close to avoid bile spillage that would confound our interpretation of ICG in the field. Using
ICG cholangiography, we identified the CHD and the takeoff of the cystic duct and the pulsatile cystic
artery [Figure 17]. The robot aided in the precise skeletonization of the junction of the infundibulum and
cystic duct to restore normal anatomy. These findings were used to confirm the CVS, and the gallbladder
was successfully resected. The absence of accumulated ICG and bile using a fluoroscopic intraoperative
cholangiogram confirmed that bile was not leaking from the prior fistula [Figure 18]. A 19-French soft
