[Intra-operative cholangiography in laparoscopic cholecystectomy]

Intraoperative cholangiography (IC) in laparoscopic cholecystectomy is a controversial issue. According to traditional teaching, the purpose of cholangiography in gallbladder surgery is to discover previously undiscovered common bile duct stones. This examination was extremely important in the era before ERCP. IC enabled surgeons to find stones and remove them at the same operation. With progress in ERCP, the importance of intraoperative cholangiography has diminished. A stone missed during surgery can most often be dealt with by the less invasive ERCP and papillotomy. There has been a difference of opinion in the literature as to whether to perform cholangiography routinely during gallbladder operations or only in cases in which there is a specific indication, such as an enlarged common bile duct, a history of pancreatitis, or elevated enzymes. Routine operative cholangiography prolongs operative time and carries its own inherent risks, such as injury to the bile ducts. The likelihood of stones is not high and over-diagnosis of stones would result in unwarranted common bile duct exploration and the danger of complications from the procedure. The tendency today is towards a more selective approach. In this era of laparoscopic gallbladder surgery, the controversy has come to the fore again, and there is now an additional aspect. In laparoscopic gallbladder surgery there is greater significance to the "road map" provided by X-rays. We rely mainly on the visual sense and have forgone the tactile sense. Therefore, any added visual input in this operation helps avoid the danger of injuring the main bile ducts. It is our contention that the indications for operative cholangiography in laparoscopic cholecystectomy should again be broadened.