An easy and effective method of cholangiography in laparoscopic cholecystectomy: laparoscopic cholecystocholangiography

Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions

Background

Bile duct injury (BDI) is a dreaded complication of cholecystectomy, often caused by misinterpretation of biliary anatomy. To prevent BDI, techniques have been developed for intraoperative assessment of bile duct anatomy. This article reviews the evidence for the different techniques and discusses their strengths and weaknesses in terms of efficacy, ease, and cost-effectiveness.

Method

PubMed was searched from January 1980 through December 2009 for articles concerning bile duct visualization techniques for prevention of BDI during laparoscopic cholecystectomy.

Results

Nine techniques were identified. The critical-view-of-safety approach, indirectly establishing biliary anatomy, is accepted by most guidelines and commentaries as the surgical technique of choice to minimize BDI risk. Intraoperative cholangiography is associated with lower BDI risk (OR 0.67, CI 0.61–0.75). However, it incurs extra costs, prolongs the operative procedure, and may be experienced as cumbersome. An established reliable alternative is laparoscopic ultrasound, but its longer learning curve limits widespread implementation. Easier to perform are cholecystocholangiography and dye cholangiography, but these yield poor-quality images. Light cholangiography, requiring retrograde insertion of an optical fiber into the common bile duct, is too unwieldy for routine use. Experimental techniques are passive infrared cholangiography, hyperspectral cholangiography, and near-infrared fluorescence cholangiography. The latter two are performed noninvasively and provide real-time images. Quantitative data in patients are necessary to further evaluate these techniques.

Conclusions

The critical-view-of-safety approach should be used during laparoscopic cholecystectomy. Intraoperative cholangiography or laparoscopic ultrasound is recommended to be performed routinely. Hyperspectral cholangiography and near-infrared fluorescence cholangiography are promising novel techniques to prevent BDI and thus increase patient safety.

A reliable method for handling the "difficult" cystic duct to obtain a good cholangiogram during laparoscopic cholecystectomy

BACKGROUND

Intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) is used to assess the anatomy of the biliary tree and to detect any stones contained within it. Intraoperative cholangiography may be performed either routinely or more selectively in cases where there is a high suspicion of choledocholithiasis or for those patients whose anatomy appears unclear at operation [8]. In cases where significant inflammation is present, the cystic duct may be short, thickened, or dilated and thus difficult to manipulate to obtain a satisfactory IOC.

METHODS

We describe a safe, simple, reliable technique to control the "difficult" cystic duct during IOC with a vascular vessel loop instead of a surgical clip to obtain good control and avoiding extravasation of dye during IOC. The feasibility, safety, and results of this technique are described.

RESULTS

During a 1-year period, this technique has been used in 10 patients, and it was successful in all attempted cases, with a good quality IOC obtained on the first attempt. The cystic duct was then occluded in all cases using a Vicryl "0" endoloop. One patient had a common bile duct stone and this patient received postoperative endoscopic retrograde pancreatography (ERCP). All patients were discharged home with no complications. In cases where a short, thickened, or dilated cystic duct was present, ductal control during IOC was easily obtained using a vascular vessel loop.

CONCLUSIONS

This is a safe, reliable, less traumatic, readily available, and inexpensive method that provides a secure way of handling the "difficult" cystic duct.

PROSPECTIVE COMPARISON OF ROUTINE AND SELECTIVE OPERATIVE CHOLANGIOGRAPHY

BACKGROUND

In a rural centre with limited resources and no endoscopic retrograde cholangiopancreatography facilities, a prospective cohort study was established to compare policies of routine and selective intraoperative cholangiography (IOC) in order to develop a local protocol.

METHODS

Patients undergoing laparoscopic cholecystectomy from 1 February 1995 to 30 November 2002 were allocated to undergo routine or selective IOC according to birth date. Those with known common bile duct (CBD) stones were excluded. Selective IOC was performed on the basis of abnormal liver function tests or a dilated CBD on ultrasound. Study end points after 12 months follow-up were retained CBD stones, CBD injury, operating times and the effect of IOC on the management of patients with persistent biliary symptoms postoperatively.

RESULTS

Of the 148 patients in the routine group, 94 underwent IOC and CBD stones were shown in 12. Of the 155 in the selective group, IOC was performed in 34 of 45 eligible patients and stones were shown in five. Sixteen patients re-presented with recurrent biliary symptoms or jaundice postoperatively and eight had proven retained CBD stones, of whom only one had undergone (false-negative) IOC. There was no significant difference in mean operating time (56 vs 61 min; t-test P = 0.15). There was one CBD injury in each group, both incurred after successful IOC.

CONCLUSIONS

There was no difference between policies of routine or selective IOC in relation to operating times, retained CBD stone rates or CBD injury. However, the authors found management of patients with recurrent biliary symptoms easier if an IOC had been performed, and IOC was easier to perform when the staff were expecting it. Thus a policy of routine IOC has been adopted.

A randomized controlled trial comparing cholecystocholangiography with cystic duct cholangiography during laparoscopic cholecystectomy

BACKGROUND

The rate of intraoperative cholangiography fell after the advent of laparoscopic cholecystectomy due to the perceived difficulty of cystic duct cannulation. It is suggested that cholecystocholangiography (CCC) is a valid and easier alternative. The present study compares cystic duct cholangiography (CDC) to CCC with evaluation of procedural time, success rate, image quality, cost and radiation exposure.

METHODS

Patients undergoing laparoscopic cholecystectomy were randomized to CCC (n = 40) or CDC (n = 36). Details of operative times, radiation exposure, and use of disposable equipment were recorded prospectively. Cholangiograms were performed using image intensification and were scored from 0 to 6 according to adequacy of images. Data were analysed on an intention-to-treat basis with the chi-squared test, t-test or Fisher's exact test.

RESULTS

The success rate for CDC was 100% and for CCC it was 72% (P = 0.0005). Patients with a failed CCC went on to have CDC for a success rate in the CCC arm of 92.5%. Comparing CDC to CCC, there was no significant difference in cost ($30.16 vs $33.36: P = 0.11), operative time (1 h 13 min vs 1 h 3 min; P = 0.19) or cholangiogram time (8 vs 9 min: P = 0.39). There was a significant difference in screening time (0:41 vs 1:33 min; P < 0.0001), adequate image quality (100 vs 72.5%, P = 0.0005) and procedure-related complications (0 vs 5; P = 0.03).

CONCLUSIONS

A significant number of CCC fail. Successful CCC provides inferior image quality and greater radiation exposure. It provides no benefit in time or cost and cannot be recommended for operative cholangiography.