Laparoscopy-guided intracorporeal ultrasound accurately delineates hepatobiliary anatomy

Summary The purpose of this study was to develop a technique and assess the ability of a laparoscopic ultrasound probe to delineate biliary antomy and to determine the presence or absence of duct stones. Methods: Five pigs had ultrasonography of biliary structures and liver at laparoscopy followed by cholangiograms and anatomical dissection. Five patients had ultrasonography of the biliary tract at laparoscopic cholecystectomy. Results: All animals had adequate visualization of important hepatobiliary structure, and an optimal method of accessing these structures at laparoscopy was established. Patients had ultrasonography which used methods developed in the animal trial. All had adequate visualization of the entire common bile duct confirmed by cholangiography. Limitations in demonstrating the relationship of the cystic duct to the common duct were technical and can be corrected. Conclusion: Laparoscopic ultrasonography has significant potential for delineation of biliary anatomy and determination of presence or absence of duct calculi. Clinical implementation could minimize the risk of iatrogenic duct injury and the need for operative cholangiography.Presented in part at the Society of American Gastrointestinal Endoscopic Surgeons Annual Meeting, April 10, 1992, Washington D.C.     

Intraoperative ultrasonography (IOUS) during laparoscopic cholecystectomy

Background: The purpose of this study was to evaluate the usefulness of intraoperative ultrasonography (IOUS), a new method of imaging the biliary tree and related structures, during laparoscopic cholecystectomy. Method: An IOUS probe (Aloka, Tokyo, Japan) with a 7.5-MHz linear-array transducer was used during cholecystectomy in 124 patients with symptomatic cholelithiasis (45 men, 79 women; mean age, 48±14 years). Results: The examination of the common bile duct (CBD) was excellent in 117 patients but unsatisfactory in 7 cases (5.6%) at the level of the head of the pancreas. In 5 patients, IOUS showed unsuspected choledocholithiasis: a subsequent intraoperational cholangiogram confirmed this. In five cases IOUS was able to help the surgeon to localize a Calot area obscured by inflammation. Postoperatively, one patient had an injury of the cystic duct stump: a nasobiliary tube resolved the bile leakage after 7 days. Another patient was submitted to postoperative endoscopic retrograde cholangiopancreatography (ERCP) for a choledocholithiasis recognized by a trans-cystic-tube cholangiography: the stone was suspected but not demonstrated either by laparoscopic IOUS or by intraoperative cholangiography. During the follow-up period, one patient had an episode of acute pancreatitis. ERCP showed a small stone wedged in the sphincter of Oddi. Conclusions: IOUS may be a real alternative to cholangiography during laparoscopic cholecystectomy since it is safer and offers a complete examination of the biliary tree. It has some disadvantages which can solved by additional experience.     

Recognition of laparoscopic bile duct injuries by intraoperative ultrasonography

Background: The purpose of this study was to investigate the possibility of detecting bile duct injuries using laparoscopic intraoperative ultrasound (LIOU). Methods: Fifty bile duct injuries were created using laparoscopic techniques in ten farmer pigs. The lesions created were: (1) partial occlusion, (2) complete occlusion (1 clip), (3) complete occlusion (2 clips), (4) transection between clips, (5) excision between clips. Results: All injuries were easily visualized using LIOU. The relation of clips impinging upon or occluding the bile duct was readily visualized on LIOU in all cases. In some cases it was difficult to distinguish between partial and complete occlusion. It was also difficult to distinguish between transection and excision due to retraction of the severed bile duct. Conclusions: In cases of iatrogenic occlusion of the bile duct involving hemoclips (including transection or excision between clips), LIOU is a potentially useful modality that may allow earlier recognition and repair. Further studies are needed to evaluate the efficacy of LIOU in detection of bile duct injuries that do not involve hemoclips.     

Prospective randomized comparison of laparoscopic ultrasonography using a flexible-tip ultrasound probe and intraoperative dynamic cholangiography during laparoscopic cholecystectomy

Background: We performed a prospective randomized comparison of laparoscopic intraoperative ultrasonography (LIOU) and dynamic intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC). Methods: LIOU and IOC were attempted in 518 consecutive patients scheduled for laparoscopic cholecystectomy. The order in which the diagnostic procedures were performed was randomly assigned. Results: LIOU failed in two patients (0.4%), and there were 41 (7.9%) failed IOC. The common bile duct (CBD) was visualized reliably with both methods. Our patients showed sensitivities of 83.3% and 100% and specificities of 100% and 98.9%, with an overall accuracy of 99.2% and 98.9% for LIOU as compared to IOC for identifying unsuspected common bile duct stones. The time necessary for the examination was significantly shorter in LIOU than in IOC (7 versus 16 min). Conclusion: LIOU performed by experienced surgeons is a good and effective method to assess the CBD, including the neighboring structures of hepatoduodenal ligament. Using powerful, flexible-tip ultrasound probes, CBD exploration can be done in a longitudinal fashion, which is necessary for good anatomical clarity. A lack of adverse effects, shorter examination times, and lower costs are some of the advantages of this method. The most important advantage is the possibility of unlimited repetition, especially if there is difficulty identifying anatomic structures. In addition, there are some indications that LIOU has the potential to recognize major iatrogenic bile duct injuries. Received: 19 December 1996/Accepted: 23 April 1997     

Long-term results of major bile duct injury associated with laparoscopic cholecystectomy

Background: Major bile duct injury (MBDI) is the most serious complication associated with laparoscopic cholecystectomy (LC). This study reports on long-term outcomes and clinical factors which predicted the outcome of 25 patients with LC-associated MBDI. Methods: Twenty-five consecutive patients receiving either primary (n = 11) or redo (n = 14) biliary reconstructive surgery at Cathay General Hospital for LC-associated MBDI were prospectively followed for 2 to 10 (mean, 4.5) years to assess their long-term outcomes. Twelve clinical factors relevant to their outcomes were analyzed. Results: There was no mortality. Although the 1-year postoperative results were successful in 23 patients (92%), the mid- to long-term outcomes were successful in only 17 patients (68%). Eight patients (32%) developed biliary strictures at an average of 3.3 years postoperatively and required subsequent reoperation or biliary stenting. Statistical comparison of 12 risk factors between the successful and unsuccessful groups revealed that two were significant, namely, repair performed by a nonreferral surgeon (p = 0.02) and repair at a stage with recent active inflammation (p = 0.04). A serum alkaline phosphatase level greater than 400 IU in the sixth postoperative month was highly correlated with long-term nonsuccess (p = 0.01). Conclusions: Only 68% of patients with LC-associated MBDI who underwent reconstructive surgery at our institution had long-term success. A serum alkaline phosphatase level above 400 IU in the sixth postoperative month was predictive of nonsuccess. For better long-term results, repair should be performed by the referral surgeon at a stage without coexisting active inflammation.     

Routine laparoscopic ultrasound can significantly reduce the need for selective intraoperative cholangiography during cholecystectomy

Background The use of intraoperative cholangiography (IOC), routinely rather than selectively, during laparoscopic cholecystectomy (LC) is controversial. Recent findings have shown laparoscopic ultrasound (LUS) to be safe, quick, and effective not only for screening of the bile duct for stones, but also for evaluating the biliary anatomy. This study aimed to evaluate, on the basis of the LC outcome and the cost of LUS and IOC, whether and how much the routine use of LUS would be able to reduce the need for IOC. Methods During LC, LUS was used routinely to screen the bile duct for stones and to evaluate the biliary anatomy, whereas IOC was used selectively only when LUS was unsatisfactory or unsuccessful. Results For 193 (96.5%) of 200 patients, LUS was completed successfully, whereas IOC was needed for 7 patients (3.5%). Bile duct stones were identified in 20 patients (10%). For the detection of bile duct stones, LUS yielded 19 true-positive, 175 true-negative, 0 false-positive, and 1 false-negative results. It had a sensitivity of 95%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 99.4%. The postoperative complications included bile leaks from the liver bed in two patients and a retained bile duct stone in one patient. If IOC had been used selectively in a traditional manner on the basis of preoperative risk factors, IOC would have been needed for 77 patients (38.5%). The total cost of LUS plus IOC for the current 200 patients was $26,256. The total estimated cost of selective IOC, if it had been performed for the 77 patients, would have been $31,416. Conclusions Routine LUS accurately diagnosed bile duct stones and significantly reduced the need for selective IOC from a potential 38.5% to an actual 3.5% without adversely affecting the outcome of the LC or increasing the overall cost. The routine use of LUS during LC is accurate and cost effective.     

Treatment of bile leaks from the cystohepatic ducts after laparoscopic cholecystectomy

The cystohepatic ducts represent accessory bile ducts of variable size which frequently travel within the gallbladder fossa or in the posterior wall of the gallbladder. These ducts can be injured during laparoscopic cholecystectomy and can result in bile collections if transected. Successful treatment by operative means or radiologically guided percutaneous drainage is possible, but endoscopic management has several advantages. We describe cases managed by endoscopic retrograde cholangiopancreatography (ERCP) with stent placement and discuss the advantages of this method. Also discussed is the anatomy of these accessory bile ducts, additional management options, and techniques for avoiding this injury during open or closed cholecystectomy.     

Routine laparoscopic ultrasonography in biliary surgery

A new technique of intraoperative imaging of the biliary tract in laparoscopic cholecystectomy is described. A specifically designed laparoscopic ultrasonographic probe is used to obtain both transverse and longitudinal views of the entire extrahepatic biliary tract. This technique was successfully used in 28 patients. The ultrasonographic imaging quality achieved equals our experience with intraoperative ultrasonography in open biliary surgery. It may be assumed, therefore, that the advantages of ultrasonography over cholangiography as documented in conventional open surgery will also apply to laparoscopic operations.     

Optimising laparoscopic cholangiography time using a simple cannulation technique

Background  Opponents of the routine use of intraoperative cholangiography (IOC) express concern over its technical difficulty and the length of time it takes. Aim  To evaluate the impact of our cystic duct cannulation (CDC) technique, as implemented by one consultant and his trainees, on the IOC time. Methods  IOC is done routinely in all the laparoscopic cholecystectomies (LCs) undertaken in our unit. We carried out a prospective audit over a period of 18 months, recording the IOC time in consecutive patients undergoing laparoscopic cholangiography (LC) with and without laparoscopic common bile duct exploration (LCBDE). The total IOC time was considered to consist of two components: cystic duct cannulation (CDC) time and fluoroscopy time. The IOC time was further analysed according to the difficulty of cannulation and the operator experience. Special consideration was given to the LCBDE cases. We also describe the detailed steps of our CDC technique. Results  Over a period of 18 months 243 patients underwent LC. IOC was completed in 240 patients (98.8% success rate). Of those, 194 were females (81%). The mean age was 50 years (range 18–85 years). The mean total IOC time was 6 min, with a CDC time of 2 min, and fluoroscopy time of 4 min. On further analysis, CDC was considered easy in 86% of cases with a mean CDC time of 1.5 min and total IOC time of 4.3 min. When cannulation was difficult (14% of cases) a cholangiography clamp had to be used to prevent leakage of contrast. In difficult cases, the CDC and IOC mean times were 5 and 8.5 min, respectively. As would be expected, trainees spent more time performing cannulation and completing the IOC than the specialist surgeon (3.8 versus 1.8 min, and 7.2 versus 5.6 min, respectively). These differences were statistically but not clinically significant. Similarly, the IOC time was also significantly increased in LCBDE (13 min). This was mainly due to an increase in fluoroscopy time (10 min) rather than CDC time (3 min). Conclusion  The IOC time could be optimised by using a simple and learnable cannulation technique to less than 5 min in most LCs. Surgeons should not, therefore, refrain from using this important investigation on selective or routine basis, subject to their policy for dealing with patients with suspected bile duct stones. Oral presentation at the 2005 EAES congress, Venice, Italy: “Optimising cystic duct cannulation and intraoperative time for consultants and trainees in laparoscopic cholecystectomy and common bile duct exploration”.     

Analysis of bile duct injuries (Stewart-Way classification) during laparoscopic cholecystectomy

In order to investigate mechanisms underlying the occurrence of bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC), we analyzed results for 34 patients (0.59%; 17 men, 17 women; average age, 57 years) with BDI out of 5750 LCs, based on questionnaire responses from surgical operators, records of direct interviews with these operators, operative reports, and videotapes of the operations. The indications for LC in the 34 patients were chronic cholecystitis in 32 patients and acute cholecystitis in 2. The BDIs in these patients were divided into four classes using the Stewart-Way classification: class I, incision (incomplete transection) of the common bile duct (CBD), n = 6 (17.6%); class II, lateral damage to the common hepatic duct (CHD), n = 9 (26.5%); class III, transection of the CBD or CHD, n = 15 (44.1%); and class IV, right hepatic duct or right segmental hepatic duct injuries, n = 4 (11.8%). In all class III and 3 class I cases (18 in total; incidence 53%), the mistake involved misidentifying the CBD as the cystic duct. Of all types (classes) of injuries, class III injuries showed the mildest gallbladder inflammation, and there was a significant (P = 0.0005) difference in the severity of inflammation between class II and III injuries. We conclude that complete transection of the CBD, which is rare in laparotomy, was the most common BDI pattern occurring during LC and that the underlying factor in the operator making this error was mistaking the CBD for the cystic duct.     

Routine versus selective intraoperative cholangiography during laparoscopic cholecystectomy

Background Routine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) is a matter of debate. Methods Data from 2,130 consecutive LCs and patients’ follow-up during 9 years were collected and analyzed. During the first 4 years of the study, 800 patients underwent LC, and IOC was performed selectively (SIOC). Thereafter, 1,330 patients underwent LC, and IOC was routinely attempted (RIOC) for all. Results In the IOC group, 159 patients met the criteria for SIOC, which was completed successfully in 141 cases (success rate, 88.6%). Bile duct calculi were found in nine patients. All other patients with no criteria or failed SIOC were followed, and in nine patients retained stones were documented. Thus, the incidence of ductal stones was 1.1% and sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) for the detection of ductal stones were 50, 100, 98.6, and 100%, respectively. In the RIOC group, IOC was routinely attempted in 1,330 patients and was successful in 1,133 (success rate, 90.9%; p = 0.015). Bile duct stones were detected in 37 patients (including 14 asymptomatic stones). In two cases, IOC failed to reveal ductal stones (false negative). There was no false-positive IOC. Therefore, with RIOC policy, the incidence of ductal stones, sensitivity, specificity, NPV, and PPV were 3.3, 97.4, 100, 99.8, and 100%, respectively (significantly higher for success rate, incidence, sensitivity, and NPV; p < 0.05). Abnormal IOC findings were also significantly higher in the RIOC group. Common bile duct injury occurred only in the SIOC group [two cases of all 2,130 LCs (0.09%)]. Conclusion RIOC during LC is a safe, accurate, quick, and cost-effective method for the detection of bile duct anatomy and stones. A highly disciplined performance of RIOC can minimize potentially debilitating and hazardous complications of bile duct injury.     

Intraoperative cholangiography facilitates simple transcystic clearance of ductal stones in units without expertise for laparoscopic bile duct surgery

Background In the absence of facilities and expertise for laparoscopic bile duct exploration (LBDE), most patients with suspected ductal calculi undergo preoperative endoscopic duct clearance. Intraoperative cholangiography (IOC) is not performed at the subsequent laparoscopic cholecystectomy. This study aimed to investigate the rate of successful duct clearance after simple transcystic manipulations. Methods This prospective study investigated 1,408 patients over 13 years in a unit practicing single-session management of biliary calculi. For the great majority, IOC was attempted. Abnormalities were dealt with by flushing of the duct, glucagon injection, Dormia basket trawling, choledochoscopic transcystic exploration, or choledochotomy. Results Of 1,056 cholangiograms performed (75%), 287 were abnormal (27.2%). Surgical trainees, operating under supervision, successfully performed 24% of all cholangiograms. Of 396 patients admitted with biliary emergencies, 94.1% had abnormal cholangiograms. Of the 287 patients with abnormal IOCs, 9.4% required no intervention, 18% were clear after glucagon and flushing, and 13% were cleared using Dormia basket trawling under fluoroscopy. A total of 95 patients required formal LBDE, and 2 required postoperative endoscopic retrograde cholangiopancreatography (ERCP). No postoperative ERCP for retained stones was required after simple transcystic manipulation. Eight conversions occurred, one during a transcystic exploration. Follow-up evaluation continued for as long as 6 years in some cases. Two patients had recurrent stones after LBDE and a clear postoperative tube cholangiogram. Conclusion In this series, 10% of the abnormal cholangiograms occurred in patients without preoperative risk factors for bile duct stones. Altogether, 88 IOCs (31%) were cleared after either simple flushing or trawling with a Dormia basket. Formal LBDE was not required for 40% of abnormal cholangiograms. Simple transcystic manipulations to clear the bile ducts justify the use of routine IOC in units without laparoscopic biliary expertise. Presented at the 12^th meeting of the EAES, Barcelona, Spain, June 2004     

Usefulness of both operative cholangiography and conversion to decrease major bile duct injuries during laparoscopic cholecystectomy

Background/Purpose We evaluated the role of operative cholangiography and of conversion to decrease major bile duct injuries.Methods We report 1074 patients who underwent laparoscopic cholecystectomy, out of a total of 1195 patients who underwent laparoscopy, over an 8-year period. The planned laparoscopic operative procedure in all the patients was the standard four-port technique with the operator on the left side of the patient. Operative cholangiography was performed with Olsens pliers.Results We performed 993 (83%) operative cholangiographies; 121 (10.1%) patients were converted from laparoscopic to open cholecystectomy. Despite a prolonged time of dissection, 54 (4.5%) patients were converted because of unclear anatomy of Calots triangle. One hundred and ninety patients suffered acute cholecystitis and, of those, 52 (27.3% of 190 patients) were converted. Fifteen patients showed intraoperative biliary duct stones and they were converted. Seven (0.58%) bile duct injuries (one stricture and six fistulas) are reported.Conclusions The low number of major bile duct injuries reported in our study showed the value of operative cholangiography during laparoscopic cholecystectomy. Moreover, another important factor found to reduce major bile duct injuries was conversion when, despite accurate dissection, the anatomy of Calots triangle remained unclear.Presented at the poster session of the 103rd Congress of The Japan Surgical Society, Sapporo, Hokkaido, Japan, June 2003, and published in abstract form in the Journal of the Japan Surgical Society (2003) 104: 1072–1073 (data-related years 1993–2000).     

The era of ultrasonography during laparoscopic cholecystectomy

BACKGROUND: The use of ultrasound cholangiography during cholecystectomy has been well described. This study was undertaken to assess the use of the umbilical port exclusively for ultrasound and to assess its employment on the use of fluoroscopy resources. In addition, we also looked at the increased use of ultrasound from 2000 to 2004. METHODS: The use of imaging techniques during all cholecystectomies was analyzed from January 2000 to July 2001 for one surgeon and compared with that surgeon's present use from January 2004 to June 2004. Patient demographics, intraoperative finding, and postoperative results were reviewed. RESULTS: During the first study period, ultrasound was used in 29% of 189 laparoscopic cholecystectomies. During 2004, ultrasound was used in 77% of 66 laparoscopic cholecystectomies. Throughout both periods, fluoroscopy was only used during 6 laparoscopic common bile duct explorations (2.4% of all cases). There were no false-positive or -negative ultrasounds, and there were no bile duct injuries. CONCLUSIONS: As experience with ultrasound cholangiography increases, there is little indication for fluoroscopic cholangiography except for rare questions concerning anatomy and during therapeutic maneuvers for common bile duct stones.     

The routine use of laparoscopic ultrasound decreases bile duct injury: a multicenter study

Objective  Laparoscopic ultrasound (LUS) has been used for over 15 years to screen the bile duct (BD) for stones and to delineate anatomy during laparoscopic cholecystectomy (LC). LUS as a modality to prevent BD injury has not been investigated in a large series. This study evaluated the routine use of LUS to determine its effect on preventing BD injury. Methods  A multicenter retrospective study was performed by reviewing clinical outcome of LC in which LUS was used routinely. Results  In five centers, 1,381 patients underwent LC with LUS. LUS was successful to delineate and evaluate the BD in 1,352 patients (98.0%), although it was unsuccessful or incomplete in 29 patients (2.0%). LUS was considered remarkably valuable to safely complete LC, avoiding conversion to open, in 81 patients (5.9%). The use of intraoperative cholangiography (IOC) varied depending on centers; IOC was performed in 504 patients (36.5%). For screening of BD stones (which was positive in 151 patients, 10.9%), LUS had a false-positive result in two patients (0.1%) and a false-negative result in five patients (0.4%). There were retained BD stones in three patients (0.2%). There were minor bile leaks from the liver bed in three patients (0.2%). However, there were no other BD injuries including BD transection (0%). Retrospectively, IOC was deemed necessary in 25 patients (1.8%) to complete LC in spite of routine LUS. Conclusion  LUS can be performed successfully to delineate BD anatomy in the majority of patients. The routine use of LUS during LC has obviated major BD injury, compared to the reported rate (1 out of 200–400 LCs). LUS improves the safety of LC by clarifying anatomy and decreasing BD injury.     

The standard of laparoscopic cholecystectomy

Background

Laparoscopic cholecystectomy today is the standard operation for all gall stone disease. Nevertheless, a number of questions are still being discussed: What are the optimal steps? Or, more important, is the laparoscopic technique really superior to the open procedure according to the criteria of evidence-based medicine? How should we proceed in case of an occult choledocholithiasis? Is intraoperative cholangiography mandatory, and does the concept for the treatment of silent gall stones need to be revised in the era of laparoscopic cholecystectomy?

Method

Literature review.

Results

Eleven randomised studies show the superiority of the laparoscopic technique. Only one study shows no advantage provided the length of the incision in the open procedure is less than 8 cm. According to our own experience, up to 98% of all gall bladders can be removed laparoscopically when following the described standard technique, with a conversion rate of less than 1%. In the case of an occult choledocholithiasis the concept of “therapeutic splitting” has proved successful; the risk of a residual stone is below 1%. Routine intraoperative cholangiography is not cost effective. The risk of complications for a silent gall stone in the long term is higher than for laparoscopic cholecystectomy in young patients with incidental gall stones.

Conclusion

The laparoscopic technique has given new impulses to the surgery of the gall bladder and has proven to be an effective, patient-friendly alternative to open surgery.

     

Laparoscopic ultrasonography as compared with static or dynamic cholangiography at laparoscopic cholecystectomy

We compared laparoscopic ultrasonography (LICU) with static (S) or dynamic (D) cholangiography (IOC) for assessment of duct anatomy and calculi in 209 patients. LICU visualized ducts in 88% compared with 93% for IOC (P=0.046). Nineteen patients (9%) had stones: 17 were found by LICU (89%) and 10 (53%) by IOC (P=0.032). Time to perform LICU (7±3 min) was less than IOC (13±6 min) (P<0.0001). Time to perform SIOC (12±5 min) and DIOC (14±6 min) did not differ (P=0.48), nor did these tests differ in accuracy. LICU provided useful anatomical information but IOC better defined anatomic anomalies. LICU required less time but was less reliable at defining anatomy and complete duct visualization. LICU was more sensitive for stones. SIOC and DIOC did not differ objectively. LICU and IOC are complementary.     

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.     

A comparison of intraoperative ultrasound versus cholangiography in the evaluation of the common bile duct during laparoscopic cholecystectomy

Indications for intraoperative evaluation of the common bile duct during laparoscopic cholecystectomy are controversial, as is the goal of either anatomic definition or assessing for choledocholithiasis. One hundred twenty-five consecutive patients undergoing laparoscopic cholecystectomy underwent both intraoperative ultrasound and intraoperative cholangiography. Cholangiography required slightly more time to perform; it was more sensitive (92.8% vs 71.4%) but less specific (76.2% vs 100%) for choledocholithiasis than was ultrasound. Ultrasound was somewhat more difficult to perform, and, particularly in the setting of intraabdominal obesity, was often inadequate at providing clear visualization of the intrapancreatic common bile duct. It did not provide the same anatomic definition as an adequate cholangiogram. The overall incidence of choledocholithiasis was 11.2%.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, TN, USA, 18–19 April 1994     

Preoperative evaluation of the extrahepatic bile duct structure for laparoscopic cholecystectomy

Background The incidence of aberrant bile duct injury associated with laparoscopic cholecystectomy (LC) has not yet been adequately examined. This study aimed to clarify the types of normal cystic ducts and the incidence of aberrant extrahepatic bile ducts, and to search for a method of avoiding injuries during LC. Methods Aberrant hepatic ducts were retrospectively categorized into five types according to the pattern of the cystic ducts and the accessory hepatic ducts by preoperative endoscopic retrograde cholangiography or multidetector three-dimensional computed tomography using drip infusion cholangiography. The aberrant bile ducts were classified as type A (merging at the right side of the common bile duct), type B (merging at the anterior side), or type C (merging at the posterior left side). Results The intrahepatic bile ducts and cystic duct were clearly shown for 1,044 of the 1,278 patients who underwent LC. Secondary branches of aberrant cystic ducts were observed in 37 cases (3.5%), and accessory hepatic ducts were observed in 30 cases (2.9%). A comparison of the difficulties encountered with LC for each type based on the merging patterns of cystic ducts showed that type C needed a much longer operation time for LC than the other types. Conclusions A preoperative evaluation of the bile duct tract and the accessory hepatic duct before LC is important. Patients with a cystic duct merging normally into the posterior left side of the common hepatic duct (type C) experienced difficulty when undergoing LC. The authors have safely performed LC with the use of an endoscopic nasobiliary drainage tube in type D cases (cystic duct merging with the right hepatic duct), in type IV cases (cystic duct merging with an accessory hepatic duct).