Selective operative cholangiography. Appropriate management for laparoscopic cholecystectomy

B. L. Robinson, J. H. Donohue, S. Gunes, G. B. Thompson, C. S. Grant, M. G. Sarr, M. B. Farnell and J. A. van Heerden
Department of Surgery, Mayo Clinic, Rochester, Minn., USA.

OBJECTIVE: To evaluate the results of selective intraoperative cholangiography (IOC) in patients undergoing laparoscopic cholecystectomy. DESIGN: Retrospective study. SETTING: Mayo Clinic, Rochester, Minn, from 1990 to 1991. PATIENTS: Five hundred forty-two patients underwent attempted laparoscopic cholecystectomy. Excluding 28 (5.2%) who underwent conversion to laparotomy and 19 (3.5%) who did not respond to a follow-up questionnaire, there were 495 respondents (mean follow-up, 25 months). MAIN OUTCOME MEASURE: Incidence and management of choledocholithiasis, extrahepatic bile duct injuries, and other findings potentially affected by IOC. RESULTS: Twenty patients underwent preoperative endoscopic retrograde cholangiopancreatography for suspected common bile duct abnormalities, and 10 had common bile duct stones removed. Nearly a third (n = 161 [32.5%]) of the patients underwent IOC for laboratory, historical, or operative findings or for training purposes. Common bile duct stones were discovered on IOC in five patients (3.1%), three of whom were treated successfully with postoperative endoscopic therapy; the two others had normal findings on endoscopic retrograde cholangiopancreatography (false-positive results of IOC). In three other patients in whom IOC was unsuccessful or incomplete, symptomatic common bile duct stones developed. Two patients were treated with endoscopic techniques, and one required open common bile duct exploration. Among the 334 patients who did not undergo IOC, symptoms suggestive of retained stones developed in eight (2.4%) (all within 2 months of surgery; mean, 18 days), but stones were found at endoscopy retrograde cholangiopancreatography in only four patients. Two had preoperative criteria for performing IOC. In only three patients (0.6%) from the study population would symptomatic retained common bile duct stones have developed with selective IOC and routinely successful IOC. No common bile duct injuries occurred. CONCLUSIONS: Selective IOC during laparoscopic cholecystectomy is a safe practice when the ductal anatomy is clearly defined and there is no laboratory or clinical evidence of common bile duct abnormalities. Symptomatic retained common bile duct stones will be infrequent, and bile duct injuries will be rare when IOC is performed for the appropriate indications. These data do not support the need for routine IOC, although this procedure is an essential tool for the laparoscopic surgeon.