Final score in laparoscopic cholecystectomy. Cholangiogram 1207, no cholangiogram 116

Selective intraoperative cholangiography should be considered over routine intraoperative cholangiography during cholecystectomy: a systematic review and meta-analysis

Background

Decades of debate surround the use of intraoperative cholangiography (IOC) during cholecystectomy. To the present day, the role of IOC is controversial as regards decreasing the rate of bile duct injury (BDI). We aimed to review and analyse the available literature on the benefits of IOC during cholecystectomy.

Methods

A systematic literature search was performed until 19 October 2020 in five databases using the following search keys: cholangiogra* and cholecystectomy. The primary outcomes were BDI and retained stone rate. To investigate the differences between the groups (routine IOC vs selective IOC and IOC vs no IOC), we calculated weighted mean differences (WMD) for continuous outcomes and relative risks (RR) for dichotomous outcomes, with 95% confidence intervals (CI).

Results

Of the 19,863 articles, 38 were selected and 32 were included in the quantitative synthesis. Routine IOC showed no superiority compared to selective IOC in decreasing BDI (RR = 0.91, 95% CI 0.66; 1.24). Comparing IOC and no IOC, no statistically significant differences were found in the case of BDI, retained stone rate, readmission rate, and length of hospital stay. We found an increased risk of conversion rate to open surgery in the no IOC group (RR = 0.64, CI 0.51; 0.78). The operation time was significantly longer in the IOC group compared to the no IOC group (WMD = 11.25 min, 95% CI 6.57; 15.93).

Conclusion

Our findings suggest that IOC may not be indicated in every case, however, the evidence is very uncertain. Further good quality research is required to address this question.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-022-09267-x.

Selective intraoperative cholangiography during laparoscopic cholecystectomy in children is justified

AIMS

Intraoperative cholangiograms (IOC) during laparoscopic cholecystectomy have been advocated to detect biliary anomalies and intraductal calculi. However, IOC increases operative time and patient irradiation, and therefore is not universally used. We hypothesise selective IOC may be a valuable tool in children.

METHODS

A retrospective case note review was performed of all children who underwent laparoscopic cholecystectomy at a single institution by a single surgeon between January 2011 and March 2017. Demographics, radiological imaging, indications for surgery and IOC, and clinical outcomes were collected. Chi-Squared and Wilcoxon Rank Sum tests were used for comparisons.

RESULTS

Sixty-two patients were reviewed. Median follow-up was 2 months (0.1-60), and 53 (85%) had complete symptom resolution following surgery. Twenty-two patients underwent IOC. Six (27%) had anomalies undetected by preoperative imaging. IOC identified common bile duct (CBD) stones in 2 patients which were cleared at laparoscopy. One patient required subsequent ERCP for impacted stones. One patient has a long common channel and pancreatitis. Two patients have CBD strictures. These last 3 are awaiting biliary reconstruction. Presence of CBD dilatation or ductal stones on preoperative ultrasound were significantly associated with positive findings at IOC. No complications resulted from IOC. Patients who did not undergo IOC did not represent with missed anomalies.

CONCLUSIONS

Despite using multimodal preoperative imaging, IOC detected biliary anomalies requiring further treatment in 6/62 (10%) of patients undergoing laparoscopic cholecystectomy. Our data support the use of IOC in selective patients with CBD dilatation or suspicion of ductal stones on preoperative imaging.

LEVEL OF EVIDENCE

Study of Diagnostic Test: Level III.

To 'gram or not'? Indications for intraoperative cholangiogram

BACKGROUND

The purpose of this study was to evaluate the current practice patterns and results for use of intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy (LC).

METHODS

We performed a retrospective review of all patients who underwent LC between January 1, 2005 and December 31, 2009. Data variables included: preoperative laboratory and radiographic studies, indication for and findings of IOC, and perioperative management of choledocholithiasis and retained common bile duct (CBD) stones.

RESULTS

There were 1,308 patients who underwent LC by 23 surgeons, of whom 266 also had an IOC (20%) performed. The majority had ultrasonography performed, 242 had an abdominal compute tomography (CT) scan, and 129 patients had a hepatobiliary iminodiacetic acid (HIDA) scan. Indications for an IOC included: diagnosis of choledocholithiasis or gallstone pancreatitis (n = 116), abnormal liver function tests (n = 187), and a dilated CBD ≥ 10 mm (n = 182). Of the 266 IOCs, 36 patients (13.5%) had a CBD stone with the majority (n = 26; 72%) having normal preoperative imaging studies. Only 6 patients (17%) with a CBD calculi on IOC underwent successful clearance of the calculi at the time of LC. Twenty-nine of the remaining 30 patients with a retained calculus on IOC underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP) with extraction of the calculi. Of the 1,042 LCs performed without an IOC, 31 patients (3%) were diagnosed with a retained stone managed successfully by ERCP.

CONCLUSION

Our data reveals that the selective use of IOC is helpful in diagnosing and clearing CBD calculi, that the use of preoperative CBD size aids in selecting patients for IOC, and that choledocholithiasis identified with IOC or after discharge can be managed successfully with ERCP.

[Cystic artery anatomy characteristics in minimally invasive surgical procedures]

Large patient series undergoing laparoscopic cholecystectomy fail to show anatomic variations which lead to intraoperative bleeding.

METHOD

Cadaver material was used and corrosion casting and postmortem arteriography were employed.

RESULTS

Three types of cystic artery were devised according to the results. Type 1 normal anatomy. Type 2 more than one artery in Calots triangle and Type 3 no artery in Calots triangle.

DISCUSSION

only 40% of the second cystic artery is present in Calots triangle. The short second cystic artery is characteristic and its most often origin is from a segmental branch of the right hepatic artery. When there is no artery in Calots triangle its origin unusual, and the artery is either on the postero-lateral side of the cystic duct or it approaches the gallbladder through hepatic tissue. The specifics of MIS approach make changes in the way we understand the anatomic variations of the cystic artery. The classification is a result of practical experience and anatomical investigations.

Laparoscopic Bile Duct Injuries: Management at a Tertiary Liver Center

Bile duct injury is a rare but morbid complication of laparoscopic cholecystectomy (LC). This study was undertaken to evaluate the management of 20 patients with bile duct injuries during LC who were referred to a tertiary center with expertise in hepatobiliary surgery and liver transplantation. Sixteen (80%) were female. Mean age was 44 (range 13–70) years. Half of the injuries were distal (Bismuth I), and nearly half were diagnosed at LC. Reoperative repair was attempted in 30 per cent. Mean interval between injury and operation was 6.55 months (range 0 to 36 months). Eighteen patients underwent Roux-en-Y hepaticojejunostomy (HJ). Of the two patients who did not undergo HJ (both Bismuth I), one was treated with transhepatic cholangiography only, and one died of multiorgan failure. There were four minor complications and one late reoperation for stricture. We conclude that bile duct injury after LC is successfully managed in a tertiary center by a hepatobiliary-liver transplant team. Principles of management include anatomic definition of injury, control of sepsis, staged approach involving interventional radiology, and operative techniques refined in liver transplantation including magnification, fine sutures, selective use of internal stent, and liver biopsy.

Laparoscopic management of bile duct and bowel injury during laparoscopic cholecystectomy

Accidental injuries to the bile duct and bowel are significant risks of laparoscopic surgery and sometimes require conversion to open surgery. Although some of the injuries related to laparoscopic cholecystectomy can be managed by endoscopic techniques, laparoscopic surgery is not yet sufficiently perfected. We investigated the efficacy of laparoscopic management combined with endoscopic tube or stent insertion in cases of bile duct and bowel injuries during laparoscopic cholecystectomy. Laparoscopic cholecystectomy was attempted on 1,190 consecutive patients between April 1992 and June 1999. The first 70 patients underwent only preoperative intravenous infusion cholangiography (IVC), and the remaining 1,120 patients were subjected to both preoperative IVC and intraoperative cholangiography. We experienced 16 cases of bile duct injury (1.4%). Five patients with circumferential injuries of the bile duct were converted to open surgery for biliary reconstruction. The other 11 patients with partial laceration injuries of the bile duct and biliary leakage from the cystic duct underwent a laparoscopic simple closure technique. In 10 of these patients, an endoscopic tube or stent was inserted on the day after surgery to facilitate biliary decompression and drainage. Bowel injuries occurred in seven patients (0.6%). Three intestinal injuries were due to careless technique, and two duodenal injuries and two intestinal injuries were related to dense adhesions. All of these injuries were successfully repaired using laparoscopic techniques, autosuturing devices, or extracorporeal suturing via the umbilical incision. No postoperative complications were identified. We concluded that the biliary injury site could be closed with a laparoscopic technique so long as the biliary injury was not circumferential. Bowel injuries also could be repaired laparoscopically.