Laparoscopic intraoperative biliary ultrasonography: findings during laparoscopic cholecystectomy for acute disease

Laparoscopic cholecystectomy (LC) is one of the most commonly performed operations, yet the frequency of bile duct injury remains unacceptably high, and up to 25% of urgent LCs are converted to the open approach. Intraoperative laparoscopic biliary ultrasonography (IOUS) allows identification of portal structures before division of any structure, but the impact of IOUS on LC for acute biliary disease has not been clearly reported. A retrospective review was conducted of all patients who underwent cholecystectomy over a 29-month period. IOUS was performed after release of the medial and lateral peritoneal attachments of the gallbladder. Of the 65 patients, 43 (66%) had an urgent operation. Mean operative time was 89.6 minutes (range 45 to 196 minutes). IOUS was used routinely, when available, in 50 patients (77%). The biliary anatomy was completely observed in 48 patients (96%). IOUS identified significant biliary abnormalities in 20 patients (40%) including presence of a foreshortened cystic duct (CD) (<1 cm) in 7 patients (14%), common bile duct stones in 4 patients (8%), abnormal CD anatomy in 4 patients (8%), and abnormal vascular anatomy in 8 patients (16%). No patient was converted to open operation, no bile duct injury occurred, and no patient required subsequent biliary intervention. IOUS is effective at observing biliary anatomy in the setting of acute disease, and may be a useful tool during these difficult cases.