Routine or Selective Intraoperative Cholangiography?: A Single-Center Analysis of 1506 Laparoscopic Cholecystectomies

Intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) helps to clarify the biliary anatomy, detect common bile duct (CBD) stones, and prevent or promptly detect bile duct injuries (BDI). However, the indication for routine or selective cholangiography remains controversial. We aimed to compare the results of a routine versus selective IOC policy during LC in an urban teaching hospital.

A prospective cohort study was designed, including a consecutive series of patients undergoing LC with either routine IOC (RC) or selective IOC (SC). SC was performed in emergent LC for cholecystitis and in patients with preoperative risk factors for CBD stones. The primary outcomes of interest were CBD stones, BDI, and anatomic variations of the biliary tract rates. Secondary outcomes of interest were the IOC success rate and readmission for residual CBD stones.

A total of 1506 patients were analyzed: 1003 (66.6%) with RC and 503 (33.4%) with SC. Demographic variables were comparable between groups. Emergent LC was more frequent in SC (RC: 29.7% vs. SC: 36.2%, P =0.01). The IOC success rate was higher in RC (RC: 93.5% vs. SC: 82.6%, P <0.001). LC with SC had higher rates of positive IOC (RC: 6.7% vs. SC: 11%, P =0.04) and CBD stones detection (RC: 6.3% vs. SC: 10.4%, P =0.05). BDI was comparable between groups (RC: 0.5% vs. SC: 0%, P =0.3%), and none of them were detected by IOC. Residual CBD stones were similar between groups (RC: 0.4% vs. SC: 0.2%, P =0.5). Overall morbidity (RC: 4.5% vs. SC: 4.9%, P =0.6), readmissions (RC: 1.2% vs. SC: 1.7%, P =0.4), and reoperations (RC: 0.7% vs. SC: 0.2%, P =0.3) were comparable between groups.

Selective use of IOC appears to be a safe and effective strategy with comparable BDI and residual CBD stone rates, compared with routine IOC. However, as selective IOC was associated with a lower success rate of IOC, surgical training for its performance should not be neglected.