Intraoperative imaging of the common bile duct: a systematic review

Benign biliary disease is a common gastrointestinal condition often requiring surgical intervention. Serious complications during minimally invasive cholecystectomy, such as bile duct injury (BDI) and retained common bile duct stones, must be minimized to improve outcomes and optimize resource use. This systematic review summarizes data comparing intraoperative cholangiography (IOC), fluorescent imaging (FI) with indocyanine green (ICG), and laparoscopic ultrasound (LUS) during laparoscopic cholecystectomy.

A systematic review was conducted to address key questions (KQs) on the use of intraoperative common bile duct imaging to prevent BDI and retained stones. Comparisons included routine IOC (KQ1 routine versus selective IOC (KQ1b) in adult and pediatric populations (KQ1p), as well as IOC versus FI with ICG (KQ2) and IOC versus LUS (KQ3). Searches were conducted in PubMed, Embase, Clinicaltrials.gov, ICTRP, and Cochrane databases. Meta-analyses were performed using random effects models (inverse variance and Mantel-Haenszel), and risk of bias was assessed using the Cochrane Risk of Bias tool and a modified Newcastle-Ottawa Scale.

Of 1,981 unique publications, 46 studies met inclusion criteria (KQ1 n = 19, KQ1b n = 7, KQ1p n = 5, KQ2 n = 6, KQ3 n = 9). IOC was associated with increased operative time (Mean difference 22.61 min [95% CI 16.87, 28.34]) and technical failure (OR 8.28 [1.02, 67.47]). Routine IOC showed trends toward reduced bile duct injury (RR 0.66 [0.08, 5.36]) and increased intraoperative stone detection (RR 2.83 [1.08, 7.41]). Compared to FI with ICG, IOC showed a trend toward fewer bile duct injuries (RR 0.33 [0.01, 8.02]) and more frequent stone identification (RR 5.00 [0.25, 102.00]). IOC also reduced the need for second imaging modalities. No differences were found in postoperative stone detection across techniques.

Routine IOC may offer advantages over selective IOC, FI with ICG, and LUS in reducing complications, but is also associated with higher technical failure and longer operative time.