Background and Aims Intrahepatic cholangiocarcinoma (ICC) is a highly aggressive primary liver malignancy, and radical resection remains the main treatment option for achieving long-term survival. Laparoscopic anatomical hepatectomy and regional lymph node dissection require precise identification of hepatic anatomy and accurate surgical manipulation. Three-dimensional visualization technology facilitates individualized preoperative surgical planning, whereas indocyanine green (ICG) fluorescence navigation provides real-time intraoperative imaging. This study investigated the clinical value of combining ICG fluorescence navigation with three-dimensional visualization technology in laparoscopic anatomical hepatectomy and regional lymph node dissection for ICC.Methods This prospective, single-center, open-label, randomized controlled study included 122 patients who underwent laparoscopic radical resection for ICC between April 2023 and April 2025. Patients were randomly assigned at a 1∶1 ratio to a conventional group or a combined group, with 61 patients in each group. Patients in the conventional group underwent laparoscopic radical resection alone, whereas those in the combined group received ICG fluorescence navigation combined with three-dimensional visualization in addition to the conventional procedure. Intraoperative parameters, short-term postoperative recovery, postoperative complications, tumor recurrence, and survival outcomes were compared between the groups. The primary endpoints were evaluated according to the intention-to-treat (ITT) principle, with per-protocol set (PPS) analysis performed as a supportive analysis.Results In the PPS analysis, the combined group had shorter hepatic portal occlusion time, less intraoperative blood loss, and a lower intraoperative transfusion rate than the conventional group (all P<0.05). The rates of compliant anatomical hepatectomy, adequate lymph node dissection, and R0 resection were higher in the combined group (all P<0.05). The combined group also had a greater total number of dissected lymph nodes and positive lymph nodes (both P<0.05), and eight satellite lesions were additionally detected in the combined group compared with none in the conventional group. The drainage tube removal time and hospital stay were shorter, and postoperative day 3 levels of alanine aminotransferase, aspartate aminotransferase, and total bilirubin were lower in the combined group (all P<0.05). The overall incidence of postoperative complications was lower in the combined group than in the conventional group (5.36% vs. 19.64%, P=0.022). The 1-year regional lymph node recurrence rate was also lower in the combined group (3.57% vs. 14.29%, P=0.047), whereas no significant differences were observed in 1-year intrahepatic recurrence or distant metastasis rates (both P>0.05). Survival analysis showed that the combined group had longer progression-free survival than the conventional group (median, 30 months vs. 26 months; P=0.037), while overall survival did not differ significantly between the groups (median, 32 months vs. 27 months; P=0.215). The ITT analysis yielded results generally consistent with those of the PPS analysis.Conclusion The combination of ICG fluorescence navigation and three-dimensional visualization technology in laparoscopic anatomical hepatectomy and regional lymph node dissection for ICC may improve the precision of anatomical localization and lymph node dissection, reduce intraoperative blood loss and hepatic portal occlusion time, and facilitate postoperative recovery. It may also reduce regional lymph node recurrence and prolong progression-free survival; however, its effect on long-term overall survival requires confirmation in larger multicenter studies.