An Alternative to Cystic Duct Marking During Intraoperative Cholangiography

Abstract

Dr William Michael Duff presented a valuable concept in his article, “Avoiding misidentification injuries in laparoscopic cholecystectomy: Use of cystic duct marking technique in intraoperative cholangiography.” Whether intraoperative cholangiography (IOC) can prevent bile duct injury has been a controversial subject. This is partly because IOC is usually performed by cystic duct cannulation. So, if the common bile duct is misidentified as the cystic duct and incised for cannulation, the resulting injury negates the benefit of IOC. Dr Duff described the placement of metal clips, as markers, on the fibroareolar tissue of the wall of the cystic duct without occluding the duct. This marks the sight for the planned clipping and division of the (assumed) cystic duct, which he verifies by cholecystocholangiography. I have successfully used this technique of partial clipping and marking of the cystic duct for several years. But partial clipping of the cystic duct can be difficult or lead to occlusion of the cystic duct. I have found that placing two clips on the cystic artery instead of the cystic duct is easier (Fig. 1). If the cystic artery cannot be isolated before division of the cystic duct, clips can be placed on the fibro-fatty tissue in the area of the cystic artery. This provides cholangiographic verification similar to that described by Dr Duff. The IOC in Figure 1 is performed by my method of dye injection into the Hartmann’s pouch of the gallbladder, and not by cystic duct cannulation. Filling of the entire gallbladder is avoided by using a Kumar Clamp (Nashville Surgical Instruments), which is a 5-mm grasper with long jaws that apply completely across the lower part of the body of the gallbladder. The clamp has a channel for insertion of a catheter that carries a short 19 gauge needle to puncture the Hartmann’s pouch for dye injection. This precludes the problem of superimposition of the distended and dye-filled gallbladder over the bile ducts during IOC. Problems related to use of the spinal needle, including puncture of the back wall of the gallbladder, dislodgement of the needle during fluoroscopy, or leakage of the dye at the needle puncture site, can be avoided because the clamp serves to secure the catheter needle in place. There are two concerns that are frequently raised for IOC performed by cholecystocholangiography or by my method. First, IOC may not be obtained if there are stones in the cystic duct or there is cystic duct obstruction. I have found that dye flows around the cystic duct stones if there is no obstruction. When there is obstruction leading to hydrops, aspiration of the gallbladder before injection of dye usually dislodges the impacted stone. Second, small stones from the gallbladder may be washed down into the common bile duct by dye injection. I would like to know if Dr Duff has encountered these problems in his series of 204 patients.