Operative Cholangiogram at Laparoscopic Cholecystectomy

In the open cholecystectomy era, the established principle for treating biliary calculi was to perform intraoperative cholangiography to diagnose and treat the concomitant common duct stone at the time of cholecystectomy. To reduce unnecessary cholangiograms, a selective cholangiogram policy based on preoperative and operative criteria was sometimes used. Although both time and cost were saved, a 4% to 10% chance of missing unsuspected common duct stones was associated with this policy. The introduction of laparoscopic cholecystectomy in Australia initially led to an abandonment of the principles of biliary surgery. Rates of intraoperative cholangiography declined as stones were either ignored or diagnosed preoperatively by endoscopic retrograde cholangiopancreatography and/or intravenous cholangiography. When stones were identified, they were treated by preoperative endoscopic sphincterotomy. This decline in cholangiography was associated with a twofold to fourfold rise in serious bile duct injury as well as a delay in its diagnosis. Over the past two years, as laparoscopic cholecystectomy has become established in Australia, practice is returning to the standards of the open cholecystectomy era. Intraoperative cholangiography rates have been increasing along with the proportion of patients having their duct stones removed laparoscopically. To succeed, this practice depends on the use of fluoroscopic cholangiography, which should be the standard of care in the laparoscopic era. With laparoscopic cholecystectomy, intraoperative cholangiography is no longer optional, but mandatory. Not only does it reduce the incidence and severity of bile duct injury, but it also trains the surgeon to develop techniques of laparoscopic duct exploration.