Is the routine use of intraoperative cholangiography during laparoscopic cholecystectomy really the key to lowering bile duct injuries?

Abstract

Bile duct injuries (BDI) during laparoscopic cholecystectomy represent a very serious complication [1–5]. Berci et al. [6] have described in a detailed and critical way how the surgeon can understand the causes of this dangerous issue and prevent them by adopting some crucial dissection and intraoperative imaging strategies. Moreover, their article deals with the treatment of common bile duct stones. An aspect particularly emphasized is the low routine use of intraoperative cholangiography (IOC) to prevent BDI. Because some clear demonstrated advantages of this diagnostic method have been reported in the literature [7–10], the authors have suggested the routine performance of IOC during each laparoscopic cholecystectomy for the future. By following this standardized rule, they believe the surgeon could better prevent and detect BDI and thus improve patient care. Is the routine use of IOC during laparoscopic cholecystectomy really the key to lowering the BDI rate? To date, the role and specific value of IOC has been the subject of much debate. Beyond the supporters of its universal application, some authors go so far as to suggest that radiographic cholangiography may itself cause BDI in addition to being time consuming [11, 12]. Surgeons widely agree that IOC is the most practical method for delineating the anatomy of the biliary tree [13, 14] and that it is the best procedure for identifying BDI. The majority of surgeons follow the strategy of a selective IOC rather than its routine use, according to their own opinion. In both cases, as already mentioned in a commentary of a recent article [15], another variable can affect the fulfilment of any BDI, as described in the study by Way et al. [16]. The authors have analyzed more than 250 laparoscopic BDIs. They believe that the ‘‘human misperception’’ has a fundamental role rather than the lack of skill or knowledge because in many cases (75 %), the operator has described the surgery as routine. Moreover, 22 % of the reports did not show anything unusual. The ‘‘misperception’’ itself was the cause for the wrong interpretation of several IOCs performed for selected patients: the cholangiograms were thought to be normal, but they were not. While recognizing the importance of the IOC, the authors emphasize the need for ‘‘an even simpler method of locating the course of the ductal system during the operation, something simpler than cholangiography or ultrasonography.’’ In the wake of this statement, we strongly believe that the use of the fluorescence imaging system could be a valid solution. Our preliminary experience has shown how the preoperative intravenous injection of indocyanine green and the use of a near-infrared light during the surgery allow for a ‘‘real-time’’ fluorescent cholangiography [17]. The interpretation of images is simpler because they appear while they are in view and so can be checked with surgical maneuvers of moving structures, unlike the static information supplied by the radiographic procedure. This challenging method is easy, feasible, and able to facilitate better understanding of the bile duct anatomy. Indeed, the fluorescent dye can be injected intravenously, thereby avoiding the risk of inadvertent damage to the bile duct by direct cannulation of the cystic duct. Moreover, a fluorescent IOC can be performed for any patients without the surgeon needing to make a selection because it is not invasive and does not require additional time. G. Spinoglio (&) A. Marano Department of General and Oncologic Surgery, SS Antonio e Biagio Hospital, Via Venezia 16, 15121 Alessandria, Italy e-mail: gspinoglio@ospedale.al.it; gspinoglio@icloud.com