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Published on: November 25, 2025
Association Between Intraoperative Cholangiogram Use and Cholecystectomy Outcomes
Cody Lendon Mullens1,2,3, Joshua K Sinamo2, Scott C Levy1,2
1Department of Surgery, University of Michigan. Ann Arbor, MI.
Journal of the American College of Surgeons
|July 20, 2026
Summary
Surgeon use of intraoperative cholangiography (IOC) during cholecystectomy did not affect bile duct injury (BDI) rates but increased downstream procedures like ERCP. Practice variation may reflect differing thresholds, not injury prevention.
Area of Science:
- Gastroenterology
- Surgical Outcomes
- Biliary Surgery
Background:
- Intraoperative cholangiography (IOC) is utilized during cholecystectomy to visualize biliary anatomy and prevent bile duct injury (BDI).
- Significant variation exists in surgeon-level IOC utilization.
- The impact of IOC use on postoperative outcomes remains unclear.
Purpose of the Study:
- To investigate the association between surgeon-level intraoperative cholangiography (IOC) utilization and postoperative outcomes following minimally invasive cholecystectomy.
- To determine if varying IOC use impacts bile duct injury (BDI) rates and subsequent procedures.
Main Methods:
- Retrospective cohort study of Medicare beneficiaries undergoing minimally invasive cholecystectomy (2011-2023).
- Surgeons categorized by IOC utilization: never (0%), selective (>0% to <90%), or routine (≥90%).
- Primary outcome: BDI requiring operative repair; Secondary outcomes: ERCP, complications, length of stay, readmission, mortality. Multivariable regression analysis performed.
Main Results:
- Among 434,696 patients, 7.6% were treated by routine IOC users, 11.4% by never users, and 81.0% by selective users.
- Adjusted bile duct injury (BDI) rates were low and did not significantly differ across IOC utilization groups.
- Postoperative ERCP utilization increased with greater IOC use (8.1% for never, 10.4% for selective, 12.0% for routine users; p<0.001).
Conclusions:
- Increased surgeon-level intraoperative cholangiography (IOC) use is associated with higher rates of downstream endoscopic retrograde cholangiopancreatography (ERCP).
- No significant difference in bile duct injury (BDI) requiring operative repair was observed across varying IOC utilization patterns.
- IOC practice variation may indicate differences in intervention thresholds rather than injury prevention, impacting decision-making and resource use.
