Partial cholecystectomy

An alternative to cholecystostomy and standard cholecystectomy for 'difficult' gall bladders has been described previously. The procedure, partial cholecystectomy, involves leaving in situ part or all of the wall of the gall bladder which lies directly in relation to the liver and/or structures in the porta hepatis. Eleven such procedures have been performed over a 5 year period, and the common indication in all was severe inflammation or fibrosis in the region of Calot's triangle. One patient developed a self-limiting postoperative bile leak. One patient has formed bile duct stones and appears to have oriental cholangiohepatitis. In the remainder of the patients, there has been no recurrence of biliary tract symptoms. The procedure is definitive and safe, and may usually be performed when cholecystostomy would have been undertaken.     

The use of laparoscopic subtotal cholecystectomy for complicated cholelithiasis

BACKGROUND: The risk of damage to the bile duct and structures in the hilum of the liver is significant when Calot's triangle cannot be safely dissected during laparoscopic cholecystectomy, and conversion to an open procedure often is performed. This is more common during emergency surgery, but may not render the procedure any easier. Traditionally, open subtotal cholecystectomy was performed, but with the advent of laparoscopic surgery, this has fallen from favor. The authors report their experience using laparoscopic subtotal cholecystectomy to avoid bile duct injury and conversion in difficult cases. METHODS: Laparoscopic subtotal cholecystectomy, performed when the cystic duct cannot be identified safely, consists of resecting the anterior wall of the gallbladder, removing all stones, and placing a large drain into Hartmann's pouch. The notes for all patients who underwent a laparoscopic subtotal cholecystectomy between 1 September 2001 and 31 December 2004 were retrospectively analyzed. RESULTS: Subtotal cholecystectomy was performed in 26 cases including 13 emergency and 13 elective procedures. The median age of the patients (15 women and 11 men) was 68 years (range, 36-86 years). The indications were severe fibrosis in 16 cases, inflammatory mass or empyema in 8 cases, and gangrenous gallbladder or perforation in 2 cases. The median postoperative inpatient stay was 5 days (range, 2-26 days). Five patients underwent postoperative endoscopic retrograde cholangiopancreatography: four for persistent biliary leak and one for a retained common bile duct stone. One patient required laparotomy for subphrenic abscess, and one patient (American Society of Anesthesiology [ASA] grade 4, presenting with biliary peritonitis) died 2 days postoperatively. One patient required a subsequent completion laparoscopic cholecystectomy for a retained gallstone. One patient had a chest infection, and two patients experienced port-site hernias. CONCLUSIONS: Laparoscopic subtotal cholecystectomy is a viable procedure during cholecystectomy in which Calot's triangle cannot be dissected. It averts the need for a laparotomy.     

Iatrogenic bile duct injury: the scourge of laparoscopic cholecystectomy

Background : Laparoscopic cholecystectomy (LC) has become the first‐line surgical treatment of calculous gall‐bladder disease and the benefits over open cholecystectomy are well known. In the early years of LC, the higher rate of bile duct injuries compared with open cholecystectomy was believed to be due to the ‘learning curve’ and would dissipate with increased experience. The purpose of the present paper was to review a tertiary referral unit’s experience of bile duct injuries induced by LC. Methods : A retrospective analysis was performed on all patients referred for management of an iatrogenic bile duct injury from 1981 to 2000. For injuries sustained at LC, details of time between LC and recognition of the injury, time from injury to definitive repair, type of injury, use of intraoperative cholangiography (IOC), definitive repair and postoperative outcome were recorded. The type of injury sustained at open cholecystectomy was similarly classified to allow the severity of injury to be compared. Results : There were 131 patients referred for management of an iatrogenic bile duct injury that occurred at open cholecystectomy (n = 62), liver resection (n = 5) and at LC (n = 64). Only 39% of bile duct injuries were recognized at the time of LC. Following conversion to open operation, half the subsequent procedures were considered inappropriate. When the injury was not recognized during LC, 70% of patients developed bile leak/peritonitis, almost half of whom were referred, whereas the rest underwent a variety of operative procedures by the referring surgeon. The remainder developed jaundice or abnormal liver function tests and cholangitis. An IOC was performed in 43% of cases, but failed to identify an injury in two‐thirds of patients. The bile duct injuries that occurred at LC were of greater severity than with open cholecystectomy. Following definitive repair, there was one death (1.6%). Ninety‐two per cent of patients had an uncomplicated recovery and there was one late stricture requiring surgical revision. Conclusions : The early prediction that the rate of injury during LC would decline substantially with increased experience has not been fulfilled. Bile duct injury that occurs at LC is of greater severity than with open cholecystectomy. Bile duct injury is recognized during LC in less than half the cases. Evidence is accruing that the use of cholangiography reduces the risk and severity of injury and, when correctly interpreted, increases the chance of recognition of bile duct injury during the procedure. Prevention is the key but, should an injury occur, referral to a specialist in biliary reconstructive surgery is indicated.     

Hemobilia

Background: Laparoscopic procedures are safe and effective treatment methods in experienced hands. However, complications have been reported for laparoscopic procedures. One of the complications of laparoscopic cholecystectomy is vascular injuries. Hepatic and cystic artery injuries may occur alone or in association with bile duct injury. Bleeding from arterial injury may be seen during operation or in the late postoperative period. One of the most significant pathologies leading to this rare phenomenon is hemobilia. Methods: We present a case of a 62-year-old woman who underwent routine laparoscopic cholecystectomy for cholelithiasis at another hospital. She presented 6 months later with the clinical feature of upper gastrointestinal bleeding. Results: There was a 42 × 40 × 11 mm anechoic lesion and an echoic pattern compatible with a metallic object was found in the subhepatic region using abdominal ultrasonography. In the endoscopic examination, fresh blood was found in the stomach. The source of hemorrhage could not be identified. Bulbus duodeni was normal but a fresh clot on the papilla of Vateri was seen on gastroduodenoscopic examination. Laparotomy was performed and the provisional diagnosis of hemobilia was reached. The injured hepatic artery and pseudoaneurysmatic structure were repaired. Conclusion: Hemobilia is a late complication of laparoscopic cholecystectomy. We believe that it is important to take into consideration that bile duct injuries may be accompanied by arterial pathology.     

Minilaparoscopic (needlescopic) cholecystectomy: a study of 1,011 cases

Background: The safety and feasibility of minilaparoscopic cholecystectomy has not been documented with a large patient sample. This study reports the results of 1,011 minilaparoscopic cholecystectomies performed in a single institution.Methods: From November 1997 to May 2002, 1,023 consecutive patients underwent minilaparoscopic cholecystectomy at National Taiwan University Hospital, Taipei, Taiwan. Patients with clinical evidence of common bile duct stones (1 patient) and combined surgery for other purposes (11 patients) were excluded. The operative indication, total operative time, conversion rate, hospital stay, morbidity and mortality of 1,011 patients were reviewed and statistically analyzed.Results: Minilaparoscopic cholecystectomy was performed in 1,009 of 1,011 patients (375 males and 636 female; mean age, 54.8 years; range 13–92 years). The total operative time was 68.8 ± 31.9 min. The total hospital stay was 2.5 ± 2 days. One patient (0.10%) underwent conversion to open cholecystectomy because of common hepatic duct laceration. One patient (0.10%) underwent conversion to standard laparoscopic cholecystectomy for control of cystic artery bleeding. Ten patients (0.99%) experienced major complications including intraabdominal abscess (1 patient), bile leakage (5 patients), major bile duct injury (2 patients), bowel injury (1 patient), and postoperative hemorrhage (1 patient). Eleven patients (1.09%) had minor complications including wound infection, incisional herniation, postoperative ileus, and acute urine retention. One patient (0.10%) with bleeding tendency succumbed to postoperative hemorrhage.Conclusions: Minilaparoscopic cholecystectomy is a technically demanding approach. Our results indicate that this procedure could be performed successfully and safely by experienced surgical teams.     

胆囊颈部结石的腹腔镜切除治疗

目的:探讨胆囊颈部结石伴发胆囊炎的腹腔镜切除方法。方法:226例胆囊颈部结石,根据胆囊炎的不同情况,分别采用胆囊顺行切除、逆行切除和顺逆结合切除方法进行治疗。结果:手术均获成功,术后恢复顺利,并发症发生率较低。结论:腹腔镜胆囊切除术中对不同情况的胆囊颈部结石采用不同的处理方法,可以有效避免术中胆管损伤等严重并发症。     

Bile duct injuries during laparoscopic cholecystectomy: a collective experience of four teaching hospitals and results of repair

BACKGROUND: Laparoscopic cholecystectomy has been performed in Singapore since 1990 and, up until the end of 1997, a total of 4445 procedures had been performed in the four major teaching hospitals. Although bile duct injuries were thought to have increased following the introduction of laparoscopic cholecystectomy, there have been no reviews done on the incidence of these injuries in the Singapore context. METHODS: The present retrospective review aimed to audit the rate of bile duct injuries in the four major teaching hospitals in Singapore and to document the results of management of these injuries. RESULTS: Of the 4445 procedures performed, there were 19 (0.43%) cases of bile duct injuries. These involved the common hepatic duct (n = 8), common bile duct (n = 10), and the right hepatic duct (n = 1). The underlying gall bladder pathology included non-inflamed gall bladders (n = 10), acute cholecystitis (n = 4), Mirrizzi's syndrome (n = 3) and mucocele of the gall bladder (n = 2). Transection of the duct accounted for the majority of the injuries. Eleven bile duct injuries were identified at the time of operation. These were primarily repaired over a T tube (n = 4) or by a bilio-enteric bypass (n = 7). The remainder were diagnosed at a median of 7 days (range: 1-556 days) after surgery with a presentation of jaundice or pain. These were repaired by bilio-enteric anastomosis (n = 7) and closure over a T tube (n = 1). Three patients developed strictures subsequently, two following bilio-enteric repair after delayed diagnosis and one following immediate primary repair over a T tube. One patient developed intrahepatic stones and required a left lateral segmentectomy. CONCLUSIONS: The experience of a 0.43% bile duct injury rate is comparable to the best results from most large series in the West. Inflammation at Calot's triangle is an important associated factor for injury. Early recognition and prompt repair affords good results, and hepaticojejunostomy is recommended as the repair of choice.     

Partial Cholecystectomy Safe and Effective

Patients undergoing surgical treatment for calculous disease were considered to have had a partial cholecystectomy performed when a part of the gall bladder wall was retained for technical reasons. Forty patients underwent partial cholecystectomy: for chronic cholecystitis (20), acute cholecystitis (4), Mirizzi''s syndrome (14), portal hypertension or partially accesible gall bladder (one patient each). Four patients (10%) developed infective complications and two patients had retained common bile duct stones. In a mean follow up period of 13 months (range 1–36 mths), only 3 patients have ongoing mild dyspeptic symptoms while the rest have remained asymptomatic. Partial cholecystectomy has been found to be a safe and effective procedure in difficult cholecystectomy situations, since it combines the merits of cholecystectomy and cholecystostomy.     

Timing of laparoscopic cholecystectomy for subacute calculous cholecystitis: early or interval--a prospective study

Background/Purpose The aim of this prospective study was to evaluate the safety and feasibility of early laparoscopic cholecystectomy for subacute cholecystitis and to compare it with interval laparoscopic cholecystectomy. Methods The study was performed in 74 patients who had been diagnosed with subacute cholecystitis between January 2000 and June 2005. The patients were divided into two groups. The early laparoscopic cholecystectomy group was composed of 31 patients who underwent laparoscopic cholecystectomy 24 h after admission to the hospital. The interval laparoscopic cholecystectomy group was composed of 43 patients who underwent laparoscopic cholecystectomy 8–12 weeks after medical treatment. Results There was no significant difference between the conversion rate, intraoperative bleeding, need for intraoperative cholangiography, minor bile duct injury, and postoperative complications in the two groups. Eleven patients in the interval group underwent urgent laparoscopic cholecystectomy or additional procedures because of recurrent cholecystitis, choledocholithiasis, or biliary pancreatitis. The early group had a significantly shorter total hospital stay (P = 0.031), lower cost of treatment (P = 0.042), and less difficulty with Calot's triangle dissection (P = 0.008). Conclusions Early laparoscopic cholecystectomy can be done without hesitation in patients with subacute cholecystitis, in the light of obstacles observed in the interval group, such as dissection difficulty, lack of success in “cooling down”, and additional problems such as choledocholithiasis and biliary pancreatitis.     

Endoscopic retrograde cholangiopancreatography in conjunction with laparoscopic cholecystectomy

Summary Laparoscopic cholecystectomy (LC) has become the primary surgical treatment for symptomatic cholelithiasis. In conjunction with the dramatic rise in LC there has been an increase in the number of endoscopic retrograde cholangiopancreatographies (ERCPs) performed. For this study, the records of patients referred to the surgical endoscopy department between January 1991 and February 1992 were reviewed. Seventy-seven ERCPs were performed in conjunction with LC. The indications for ERCP included jaundice or a history of jaundice, gallstone pancreatitis, a suspicious filling defect on either ultrasound or intraoperative cholangiogram, abnormal liver function tests, cholangitis, or postoperative bile leak. Sixty-two procedures were performed prior to LC and 15 procedures after LC. Forty-two patients were female (54.5%) and the patients ages ranged from 14 to 92 years (mean 54.1 years). Of the 62 patients having ERCP preoperatively 35 patients (56.5%) had no evidence of common bile duct (CBD) stones and underwent LC as planned. Twenty-three patients were found to have CBD stones, of which six were referred for an open cholecystectomy and CBD exploration, because of large multiple CBD stones or the presence of a large duodenal diverticulum. Seventeen patients had their CBD cleared endoscopically, and four patients were not successfully cannulated.Fifteen patients had ERCP after LC. There were two patients with CBD injuries who were referred for surgical correction. Two patients had leakage from the cystic duct stump, and four patients had CBD stones, all of whom were successfully treated with endoscopic sphincterotomy. There were four patients who had a normal postoperative ERCP and two patients who could not have their CBD cannulated.There were no mortalities, but there were four cases of complications. Two patients had bleeding after stone extractions, and they required blood transfusions. One patient developed cholangitis from stenosis of the papilla after an endoscopic sphincterotomy, and one patient developed pancreatitis which resolved with conservative treatment. There is an increasing role for ERCP and sphincterotomy in patients undergoing LC. ERCP carries an inherent morbidity and therefore routine ERCP is not justified. However, with the proper suspicion of CBD stones a preoperative ERCP is indicated prior to a planned laparoscopic cholecystectomy.     

Urgent Cholecystectomy for Acute Cholecystitis in a District General Hospital – Is it Feasible?

INTRODUCTION

Laparoscopic cholecystectomy has become the gold standard for treatment of symptomatic gall stone disease. However, its place remains controversial in the management of acute cholecystitis due to a high reported incidence of bile leaks and conversion rate. Tertiary referral centres have reported good results. We present a series of cases after the introduction of an urgent cholecystectomy pathway in a district general hospital.

PATIENTS AND METHODS

A practice of urgent cholecystectomy for acute cholecystitis was introduced by three consultant general surgeons. All prospective patients having an urgent laparoscopic cholecystectomy for acute cholecystitis, over an 8-month period were entered into a database. A dedicated ultrasound service was instituted to provide prompt diagnosis in these patients. Their demographic details, operative findings, laboratory results were recorded in a prospective database. Timing of ERCP, postoperative complications and conversion rate and hospital stay were also noted.

RESULTS

There were 64 patients in the study with a median age of 51 years (range, 21–84 years). There were 21 males and 43 females. All patients underwent laparoscopic cholecystectomy during the index admission. Eleven patients had pre-operative ERCP and 12 patients had on-table cholangiogram. There were no conversions. Postoperative ERCP was required in six patients. The median time interval between admission and operation was 3 days (range, 2–7 days). There were two bile leaks but no common bile duct injury. There were two cases of superficial wound infection. One patient required re-operation for smail bowel obstruction secondary to a port site hernia.

CONCLUSIONS

Urgent laparoscopic cholecystectomy for acute cholecystitis is a feasible treatment option in a district general hospital. A safe practice can be ensured by adherence to a care pathway and a multidisciplinary, consultant-delivered service. Urgent cholecystectomy service can be provided safely in a district general hospital with outcomes comparable to previously published literature.     

Gallstones: best served hot.

BACKGROUND: Acute episodes of gallstone-related diseases have traditionally been managed conservatively. In the event of gallstones obstructing the common bile duct, patients had endoscopic extraction of calculi with interval cholecystectomy after 4 weeks to 6 weeks when acute inflammatory changes have subsided. This placed the patient at risk of recurrent cholecystitis, pancreatitis, or other complications of cholelithiasis. METHODS: Patients presenting with acute gallstone-related diseases were investigated and underwent laparoscopic cholecystectomy during the same admission according to a predetermined treatment protocol. RESULTS: All patients (119) treated according to the study protocol had good results, with no 30-day mortality and no biliary tract injuries. One patient had bleeding from the cystic artery, and 6 patients required conversion to open cholecystectomy. CONCLUSION: Growing expertise in laparoscopic cholecystectomy has made it possible for surgeons to perform safe cholecystectomy in the presence of acute gallstone-related disease. Our experience of managing gallstone disease with prompt cholecystectomy during the index admission shows that this approach provides better, safer, and more cost-effective patient care.     

Evaluation of fundus-first laparoscopic cholecystectomy.

OBJECTIVES: Laparoscopic cholecystectomy is the gold standard for gallbladder surgery. Cholecystectomy from the fundus to the cystic duct may be advantageous when cystic duct exposure becomes difficult due to adhesions on Calot's triangle. The aim of this study was to compare conventional laparoscopic cholecystectomy with the fundus-first procedure and to evaluate whether the fundus-first technique can prevent conversion in difficult cases. METHODS: The study included 145 patients treated over 18 months. The inclusion criterion was the presence of ultrasound proven gallstones. Patients were excluded from the study if there was evidence of common bile duct stones, a bilioenteric fistula, or carcinoma of the gallbladder. RESULTS: The fundus-first approach was started in 45 patients; all procedures were completed laparoscopically. Conventional laparoscopic cholecystectomy was begun in 100 patients. Twenty-seven of the 100 patients were converted to fundus dissection (adhesions within Calot's triangle). Four of the 27 were further converted to open surgery. One patient had a drop in blood pressure on creation of pneumoperitoneum. Time taken for severely inflammatory and noninflammatory cases was significantly greater (P<0.05) in the fundus-first group. The average hospital stay was 48 hours in both groups. No major complications were observed. CONCLUSION: The rate of conversion in the conventional laparoscopic cholecystectomy group decreased from 18.75% (27/144) to 2.08% (3/144). The fundus-first technique has the potential to decrease conversion in difficult cases.     

Urgent laparoscopic cholecystectomy in the management of acute cholecystitis: timing does not influence conversion rate

Background The optimal treatment of acute cholecystitis is urgent laparoscopic cholecystectomy. Most reports suggest that a delay of 72 or 96 h from onset of symptoms leads to a higher conversion rate. This study assessed the conversion rate in relation to the timing of urgent laparoscopic cholecystectomy for acute cholecystitis. Methods During a 12 month period, 112 patients received laparoscopic cholecystectomy for acute cholecystitis at a tertiary care university hospital in central Taiwan. Data were collected prospectively. Results The overall conversion rate was 3.6% (4/112). Of 62 procedures performed within 72 h from onset of symptoms, 2 were converted, as compared with 2 of 50 procedures after 72 h. Of 76 procedures performed within 96 h from onset of symptoms, 3 were converted, as compared with 1 of 36 procedures after 96 h. There were no mortalities or common bile duct injuries. Conclusions The conversion rate for urgent laparoscopic cholecystectomy among patients with acute cholecystitis can be as low as 3.6%. The timing of urgent laparoscopic cholecystectomy has no impact on the conversion rate.     

Bile leakage following laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) is now the treatment of choice for gallstones, but there has been concern that bile leakage with LC is more frequent than after open cholecystectomy (OC). We have analyzed our experience of this complication with regard to both its incidence and management.From a consecutive series of 500 LC, in which both operative cholangiography and drainage of the gallbladder bed were routine, bile leakage was identified in ten patients (2%). There was no bile duct injury. Nine of the ten patients presented with bile in the drain within 24 h of operation and one patient presented 1 week after operation with a subphrenic collection. Of the ten patients, five settled spontaneously. Of the five remaining patients, two needed laparotomy—one for a subphrenic collection not responding to percutaneous drainage and one for biliary peritonitis. One patient was treated by relaparoscopy and suture of a duct of Luschka and one patient had successful percutaneous drainage of an infected collection; the fifth patient who presented with a late subphrenic collection of bile was shown at endoscopic retrograde cholangiopancreatography (ERCP) to have a cystic duct stump leak and was treated with an endoscopic stent.Bile leakage is seen more frequently after LC than OC for reasons that are currently unclear. We believe that the use of routine gallbladder bed drainage is justified for this reason alone. The majority of bile leaks settle either spontaneously or with minimally invasive intervention.     

Laparoscopic cholecystostomy with delayed cholecystectomy as an alternative to conversion to open procedure

Background: Acute cholecystitis carries the highest incidence of conversion from planned laparoscopic cholecystectomy to open surgery due to unclear anatomy, excessive bleeding, complications, or other technical reasons. Methods: Laparoscopic tube cholecystostomy was performed instead of immediate conversion to laparotomy in 9 patients with acute cholecystitis after unsuccessful attempts at laparoscopic dissection. Elective laparoscopic cholecystectomy was done 3 months later. Results: Following this approach eight patients were treated successfully. After 3 months the acute process had subsided sufficiently to allow a safe laparoscopic cholecystectomy. One additional patient died of acute leukemia 6 weeks after cholecystostomy. Before adopting this technique we subjected 171 patients with acute calculous cholecystitis to laparoscopic cholecystectomy; there was an 11% (19 cases) rate of conversion. Since cholecystostomy has begun to be offered as an alternative to conversion, 121 patients with acute cholecystitis have had laparoscopic cholecystectomy and only 2 cases (1.5%) have been converted to immediate open cholecystectomy. Conclusions: We recommend the alternative of performing a cholecystostomy with delayed laparoscopic cholecystectomy instead of conversion to open procedure when facing a case of acute cholecystitis not amenable to laparoscopic cholecystectomy.     

Managing bile duct injury during and after laparoscopic cholecystectomy

Laparoscopic cholecystectomy is now the treatment of choice for gallstones, but there has been concern that bile leakage after a laparoscopic cholecystectomy is more frequent than after an open cholecystectomy. We have experienced 16 patients with bile duct injury after a laparoscopic cholecystectomy. Five patients had a circumferential injurury to the major bile duct, and we employed a converted open technique for biliary reconstruction. The other 11 patients had partial injurury to the major bile duct, and we performed laparoscopic restoration; all 11 of these patients received endoscopic retrograde cholangiography (ERC) on the day after the operation and stenting for biliary decompression and drainage. No complications were identified and the duration of hospitalization in these patients was significantly shorter than in those who had the converted procedure. If intraoperative cholangiography is performed routinely, the presence and form of bile duct injury can be clearly identified, and the decision to restore the site of injury or to convert to the open technique for biliary reconstruction can be made immediately. Received for publication on May 26, 1998; accepted on Aug. 28, 1998     

Bile Duct Injury After Single Incision Laparoscopic Cholecystectomy

Background:

The advancement and development of laparoscopic cholecystectomy revolutionized surgery and case management. Many procedures are routinely performed laparoscopically. Single incision laparoscopic surgery has been introduced with the hope of further reduction of scarring and possibly procedural pain. With no established technique for this procedure, the safety of single incision laparoscopic cholecystectomy has not been determined.

Methods and Results:

A 30-year-old man underwent single incision laparoscopic cholecystectomy for symptomatic cholelithiasis at an outside hospital. The operation was uneventful, and the patient was discharged home. The patient returned to the Emergency Department 4 days postoperatively, and a bile duct injury was diagnosed. A percutaneous drain was placed, and the patient was transferred to the Hepato-Pancreato-Biliary (HPB) service of a tertiary care center for definitive care. A delayed repair approach was used to allow the inflammation around the porta to decrease. Six weeks after injury, the patient underwent Roux-en-Y hepaticojejunostomy. The patient did well postoperatively.

Conclusion:

Although single incision laparoscopic surgery will play a prominent role in the future, its development and application are not without risks as demonstrated from this case. It is imperative that surgeons better define the surgical approach to achieve the critical view and select appropriate patients for single incision laparoscopic cholecystectomy.     

The importance of intraoperative cholangiography during laparoscopic cholecystectomy.

Laparoscopic cholecystectomy (LC) using an electrosurgery energy source was successfully performed in 59 (95%) out of 62 selected patients. The procedures were performed by different surgical teams at Trakya University, Medical Fakulty, in the department of General Surgery and the Karl-Franzens-University School of Medicine, in the department of General Surgery. Cholangiography was routine at Karl Franzens University and selective at Trakya University. Laparoscopic intraoperative cholangiography (IOC) was performed in 48 (81.3%) patients, and open IOC was performed in 3 patients. Two patients had common duct stones; one of which was unsuspected preoperatively. These cases underwent endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic papillotomy (EP). One patient had a choledocal tumor, unsuspected preoperatively. Anatomical anomalies were not identified. Cholangiography could not be performed in one case in which there was no suspected pathology. ERCP was performed on one patient 30 days after being discharged because of acute cholangitis. In this case, residual stones were identified in the choledocus. Four patients underwent open cholecystectomy because of tumor, unidentified cystic duct or common bile duct pathology that could not be visualized on the cholangiogram. Our study suggests that cholangiography performed via the cystic duct before any structures are divided can prevent the most serious complication of laparoscopic cholecystectomy--common duct injury. We recommend that cholangiography be attempted on all patients undergoing LC.