Intraoperative cholangiography during laparoscopic cholecystectomy

An audit of routine intraoperative cholangiography in a consecutive series of 496 patients undergoing laparoscopic cholecystectomy has been performed. Cannulation of the cystic duct was possible in 483 patients (97%). The use of portable, digitized C-arm fluorocholangiography was vastly superior to the employment of a mobile x-ray machine and static films in terms of reduced time to carry out the procedure and total abolition of unsatisfactory radiological exposure of the biliary tract. Repeat of the procedure was necessary in 22% of cases when the mobile x-ray equipment was used. Aside from the detection of unsuspected stones in 18 patients (3.9%), routine intra-operative cholangiography identified four patients (0.8%) whose management would undoubtedly have been disadvantaged if intraoperative cholangiography had not been performed.     

Intraoperative cholangiography time in laparoscopic cholecystectomy

Background: The debate for and against the routine use of intraoperative cholangiography (IOC) continues. One of the main arguments against the routine use of the technique during laparoscopic cholecystectomy (LC) is the length of time it takes, which in turn increases the cost. In this study, we recorded the time spent by the radiographer providing IOC service in the context of optimizing the utilization of the radiographer and IOC time. Methods: A total of 91 consecutive LCS, including 19 laparoscopic bile duct explorations, from April 2003 to January 2004 were included in the study. We recorded the time the radiographer took from receiving a call to arriving in the theater, the time he or she spent performing the IOC, and the total time spent in theater. We also recorded the total operative time. Results: The mean time from call to arrival was 9 min (SD = 3, n = 91). The mean total time spent by the radiographer in the theater involved in performing the IOC during LC was 15 min (SD = 8, n = 72), and that during laparoscopic exploration was 46 min (SD = 20, n = 19). The mean operative time was 67 min (SD = 24) and 135 min (SD = 59), respectively. Conclusion: Radiographer services as well as IOC time could be optimized to facilitate the routine use of this important technique in LC. Optimizing the logistics and time factor in IOC is an integral component of single-stage management of patients with suspected bile duct stones. Paper Presented at the 12th congress of the European Association for Endoscopic Surgery, Barcelona, Spain, June 2004.     

Intraoperative cholangiography in laparoscopic cholecystectomy during residency in general surgery

BACKGROUND: The role of laparoscopic intraoperative cholangiography (IC) in the diagnosis of asymptomatic choledocholithiasis is still controversial. The aim of this study was to evaluate the diagnostic-therapeutic impact and the educational implications of this method for residents specializing in general surgery. METHODS: We reviewed the records of 835 patients who underwent laparoscopic cholecystectomy for cholecystolithiasis without choledocholithiasis. IC was routinely performed by both expert surgeons and residents in general surgery. RESULTS: The cholecystectomy was completed laparoscopically in 804 cases, but conversion to open surgery was required in 31 cases. IC was not completed in 140 cases (17.4%), and in 44 cases it revealed a suspected choledocholithiasis. The stones were treated via laparoscopy in 36 cases, laparotomy in six cases, and endoscopic retrograde cholangiopancreatography (ERCP) in two cases. Five patients were not diagnosed wit h choledocholithiasis. In one case, a lesion of the choledochus was discovered and treated laparoscopically. A total of 610 IC were done by expert surgeons and 225 by residents. The duration of the cholecystectomy with IC was significantly different between the two groups (76.9 +/- 12 vs 92.4 +/- 11), as was the feasibility index (88.6% vs 80.6%). CONCLUSIONS: Laparoscopic IC is a safe and accurate procedure for the diagnosis of unrecognized choledocholithiasis. Teaching of this procedure as part of the specialization in general surgery would be opportune because it would provide surgical residents with an additional tool for the diagnosis and treatment of this pathology of the common bile duct.     

术中胆道造影在腹腔镜胆囊切除术中发现胆道损伤的作用

目的：评估术中胆道造影（IOC）在早期发现腹腔镜胆囊切除术（LC）术中胆道损伤的作用。方法：回顾分析31例LC术后胆道损伤的部位，机理，诊断时间，治疗方法及结果，并对是否行IOC进行评估。结果：胆道错认引起胆道损伤共19例，其中12例IOC显示胆道错认，致胆道部分切开损伤，腹腔镜下行I期修复或开腹修复，T管引流，但无并发症。19例中3例IOC误读及4例未行IOC患者中发生迷走胆管损伤2例，胆总管完全离断1例，胆总管完全离断合并胆道缺损2例，本组有2例损伤发生于IOC后，结论：行IOC并正确阅读可及时发现腹腔镜胆囊切除术中胆道错认所致的胆道损伤，从而防止随之可能发生的严重并发症。     

Intraoperative cholangiography using an endoscopic nasobiliary tube during a laparoscopic cholecystectomy

Purpose  

The goals of this report are to present the characteristics of biliary complications associated with laparoscopic cholecystectomies (LC) performed at a single center, and to evaluate the efficacy of intraoperative cholangiography (IOC) using an endoscopic nasobiliary tube (ENBT) during an LC in order to prevent biliary complications.     

术中胆管造影在复杂类型腹腔镜胆囊切除术中的临床应用价值

目的:研究术中胆管造影在复杂类型LC中的临床应用价值。方法:在LC中,为复杂类型胆囊炎56例行术中胆道造影。结果:56例中除1例胆囊管结石嵌顿靠近胆总管侧插管失败外,余腹腔镜手术均获成功,成功率为98.2％。结论:在复杂类型胆囊炎患者中开展术中胆管造影摄片,可辩认三管关系,了解胆囊管的长度,明确有无胆囊管或胆总管结石残留,了解胆总管下段有无相对性狭窄,避免损伤右肝管、肝总管、胆总管,提高了LC的安全性,降低了LC中转率及并发症发生率     

Intraoperative cholangiography in laparoscopic cholecystectomy for acute cholecystitis

In our prospective study we wanted to prove whether the safety of laparoscopic treatment of acute cholecystitis could be improved by intraoperative cholangiography. From July 1993 to June 1998 210 patients with acute cholecystitis underwent a laparoscopic cholecystectomy. In 23 cases (10.9%) a conversion was necessary. 189 patients underwent a laparoscopic cholangiography. In 2 cases (1.1%) an incision of the common bile duct was detected which had been mistaken for the cystic duct. So the cutting of the common bile duct could be prevented. In 12 patients (6.3%) unknown common bile duct stones were found. The complication rate was 9.5% without any mortality or major injury of the common bile duct.     

腹腔镜胆囊切除术中胆道造影方法的改进

为提高LC中胆道造影的质量 ,笔者采用自制造影器械对LC术中胆道造影方法进行了改进 ,临床应用 50例 ,全组成功率 1 0 0 %。笔者认为 ,该方法操作简单 ,成功率高。     

Cystic duct cholangiography during laparoscopic cholecystectomy

At present, there is no consensus regarding the routine use of intraoperative cholangiography during cholecystectomy. We describe a reliable technique for performing cystic duct cholangiography during laparoscopic cholecystectomy. Using this technique, we were able to cannulate the cystic duct in 97% of patients, completely visualize the biliary tree and duodenum in 93% of patients, and identify unsuspected choledocholithiasis in 3% of patients. Treatment options for the management of choledocholithiasis demonstrated by cholangiograms during laparoscopic cholecystectomy include conversion to an open cholecystectomy and common duct exploration, or endoscopic sphincterotomy and common duct stone extraction following laparoscopic cholecystectomy.     

Peroperative cholangiography during laparoscopic cholecystectomy]

The aim of this study was to assess the ease and the success of a laparoscopic technique of cholangiography. Following an initial period of training to gain expertise in laparoscopic surgery, 70 patients were included in the study. Six of them had a history of suggestive choledocholithiasis. Intraoperative cholangiography was performed using an angled catheter (Judkins) and a specific tubular cannula (Olsen, Storz) designed to guide and maintain the catheter in the cystic duct. Catheterization of the cystic duct and cholangiography were achieved in 61 patients. In 3 cases, stones were found in the common bile duct. The mean duration of the examination was 11 minutes (6.21). Cholecystectomy was performed after cholangiography. No biliary injuries were observed. These results show that intraoperative laparoscopic cholangiography is easy and not time-consuming. It obviates the need for preoperative investigations looking for biliary stones and provides an excellent definition of the biliary anatomy for safety purposes.     

Percutaneous transcholecystic cholangiography during laparoscopic cholecystectomy.

BACKGROUND: Controversy still exists regarding the role of routine cholangiography in laparoscopic cholecystectomy. Although the need to identify common bile duct stones is perhaps less critical than it was in the past, confirmation of anatomy by peroperative cholangiography is important for both clinical and medico-legal purposes. Conventionally, contrast has been introduced into the biliary tree via the cystic duct after dissection of Calot's triangle. METHODS: A simple technique of cholangiography by direct gall-bladder puncture is described, which can be done quickly and easily at the beginning of the operation. RESULTS: The retrospective analysis of 250 consecutive cases shows the technique to be safe, accurate and to provide useful cholangiograms in 85% of cases. CONCLUSIONS: Percutaneous transcholecystic cholangiography can be performed readily without special equipment. It provides valuable anatomical information in 85% of cases before commencing dissection of the cystic duct.     

The importance of intraoperative cholangiography during laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) using electrocoagulation was successfully performed in 56 out of 58 selected patients. Cholangiography was performed in 53 patients. Six patients had common duct stones; five were unsuspected preoperatively. After the gallbladder was removed, three patients underwent open common duct exploration. In another five cases, anatomical anomalies were discovered. Cholangiography performed via the cystic duct before any structures are divided can prevent the most serious complication--common duct injury. Cholangiography should be attempted on all patients undergoing LC.     

Justification for routine cholangiography during laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has been accepted by surgeons in the United States with unprecedented rapidity. Since introduction it has become, in many areas, the standard of care for treating patients with cholelithiasis. However, as with all new surgical procedures, complications are being recognized. Bile duct injuries are a complication of laparoscopic cholecystectomy, perhaps with greater incidence than with traditional cholecystectomy. Routine cholangiography may minimize the incidence of common bile duct injury. We review our experience with laparoscopic cholangiography and suggest methods to avoid common bile duct injury.     

Routine versus selective intra-operative cholangiography during laparoscopic cholecystectomy

Opinion is divided whether intra-operative cholangiography should be performed routinely or on a selective basis during laparoscopic cholecystectomy. We therefore performed the first prospective randomized trial of static cholangiography in patients who did not have indications for cholangiograms. Laparoscopic cholecystectomy was attempted on 164 consecutive patients, of whom 49 (30%) patients were excluded from the trial due to indications for or against cholangiography. In the remaining 115 (70%) patients, 56 were randomized to the cholangiography group while 59 patients did not receive cholangiograms. Duration of postoperative hospitalization and interval to return to full activity were identical in the two groups. Static cholangiograms added 16 ± 1 min (mean ± SEM) to the procedures (p<0.01). Cholangiography increased the total charges for the operation by almost $700 (p<0.01). Cholangiograms were performed successfully in 94.6% of the patients and changed the operative management in 4 (7.5%) patients. There was 1 (1.9%) false negative study. Intra-operative cholangiography did not reveal aberrant bile ducts at risk of injury from the operative dissection. There was no mortality or cholangiogram-related morbidity in either group. In follow-up ranging from 2–12 months, there has been no clinical evidence of bile duct injury or retained common bile duct stones. In summary, in patientswithout indications for cholangiography, the performance of static cholangiograms markedly increased the operative time and cost of laparoscopic cholecystectomy. The operative management of a minority of patients was changed by the information obtained, but laparoscopic cholecystectomy may be performed safely in the absence of cholangiograms with little risk of injury to the major ductal system or retained calculi.

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Resumen Las opiniones se encuentran divididas respecto a si se debe realizar colangiografía intraoperatoria en forma rutinaria o en forma selectiva en el curso de una colecistectomía laparoscópica. Por ello hemos realizado el primer estudio aleatorizado de colangiografía estática en pacientes que no tenían indicaciones para colangiograma. Se intentó la colecistectomía laparoscópica en 164 pacientes consecutivos; 49 (30%) fueron excluidos debido a indicaciones en favor o en contra de colangiografía. Los otros 115 pacientes (70%) se repartieron al azar 56 a colangiografía y 59 al grupo de no colangiografía. La duración de la hospitalización postoperatoria y del tiempo de retorno a actividad normal fueron idénticos en los dos grupos. Los colangiogramas estáticos añadieron 16 ± 1 min. al procedimiento (p<0.01) y elevaron el costo de la operación en $700 (p<0.01). Los colangiogramas fueron exitosamente realizados en 49.6% de los pacientes y modificaron el manejo operatorio en 4 (7.5%); hubo un falso positivo (1.9%). La colangiografía intraoperatoria no reveló la prescencia de canales biliares aberrantes en riesgo de lesión por la disección opeatoria. No hubo mortalidad o morbilidad relacionada con la colangiografía, y en un seguimiento de 2–12 meses no se registró evidencia clínica de lesión de canales biliares o de cálculos retenidos en el colédoco. En resumen, en pacientes sin indicaciones para colangiografía, la realización de colangiogramas estáticos aumentó notoriamente el tiempo operatorio y el costo de la colecistectomia laparoscópica. Aunque el manejo operatorio de una minoría de pacientes sí fue modificado por la información obtenida, se considera que la colecistectomía laparoscópica puede ser practicada en forma segura en ausencia de colangiogramas con mínimo riesgo de lesión del sistema biliar o de cálculos retenidos.

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Résumé Les avis sont partagés quant à la pratique systématique, ou seulement élective, d'une cholangiographie lors de la cholécystectomie coelioscopique. Nous avons mené le premier essai randomisé prospectif de cholangiographie peropératoire chez des patients n'ayant pas d'indication formelle de cholangiographie. Dans une série de 164 cholécystectomies coelioscopiques consécutives, 49 patients (30%) ont été éliminés de l'étude parce qu'il existait une indication ou une contreindication formelles à la cholangiographie peropératoire. Les 115 patients restants (70%) ont été randomisés; 56 ont eu une cholangiographie alors que 59 n'ont pas eu de cholangiographie peropératoire. La durée de l'hospitalisation postopératoire et le délai entre l'intervention et la reprise de travail étaient similaires dans les deux groupes. La cholangiographie a prolongé l'intervention de 16 ± 1 min (moyenne ± écart type de la moyenne) (p<0.01). Le coût supplémentaire d'une cholangiographie peropératoire a été estimé à environ 700 $ US (p<0.01). La cholangiographie a pu être effectuée chez 94.6% des patients, et celle-ci a changé la tactique opératoire chez 4 (7.5%) patients. Il y a eu un résultat faussement négatif (1.9%). La cholangiographie peropératoire n'a pas montré d'anomalie anatomique des voies biliares pouvant les compromettre lors de la dissection. La mortalité a été nulle dans chaque groupe. De même, il n'y a eu aucune morbidité en rapport direct avec la cholangiographie. Dans la période du suivi allant de 2 à 12 mois, il n'y a eu acune lésion biliaire ni de lithiase résiduelle de la voie biliaire cliniquement évidentes. En conclusion, chez un patientsans indication formelle de cholangiographie, la réalisation d'une cholangiographie peropératoire augmente considérablement la durée et le coût de l'intervention. La tactique opératoire a été très peu influencée très peu par les donées de la cholangiographie. La cholécystectomie coelioscopique peut être réalisée sans cholangiographie peropératoire systématique sans augmenter pour autant le risque de lésions des voies biliaires ou de calcul résiduel.

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Presented in abstract form at the Society of American Gastrointestinal Endoscopic Surgeons, April 11–12, 1992.