Routine Intraoperative Cholangiography Research Articles

Biliary Tract Imaging for Retained Calculi After Laparoscopic Cholecystectomy

The aim of this study was to determine the incidence of common bile duct (CBD) calculi patients undergoing laparoscopic cholecystectomy (LC) without routine intraoperative cholangiography (IOC) and the usefulness of risk stratification in guiding appropriate biliary tract imaging. Five hundred forty consecutive LCs were performed during the 12-month study period. Four hundred fifty-eight (84.8%) patients with low risk of CBD stones proceeded immediately to LC. Forty-four (8.1%) high-risk patients underwent endoscopic retrograde cholangiopancreatography (ERCP). Thirty-four (6.3%) moderate risk patients underwent magnetic resonance cholangiopancreatography. Four (0.7%) patients had an equivocal risk with 2 undergoing IOC. The preoperative incidence of CBD stones was 29/540 (5.4%), while 11 patients (2.04%) were readmitted with retained CBD calculi and underwent successful stone extraction with ERCP. The incidence of retained CBD calculi after LC without IOC is low. Risk stratification helps to accurately predict CBD stones and facilitates appropriate and cost-effective use of ERCP and magnetic resonance cholangiopancreatography.

Intrahepatic choledochoscopy during trans-cystic common bile duct exploration; technique, feasibility and value

Transcystic laparoscopic common bile duct exploration (TC-LCBDE) is advantageous for exploring the bile duct. Choledochoscopy, however, may be quite challenging to perform transcystically because the cystic duct is usually narrow, duct anatomy may be unfavorable, and not all stones are amenable to transcystic extraction. Convention suggests that it is technically very difficult to visualize the intrahepatic bile ducts with transcystic choledochoscopy, due to the angle of insertion of the cystic into the common bile duct (CBD). However, we have performed intrahepatic choledochoscopy successfully, moving the choledochoscope from the CBD into the common hepatic duct by using what we have termed a "wiper blade maneuver". The purpose of this study was to confirm how often this was possible. A search of a prospectively collected database of patients undergoing routine intraoperative cholangiography (IOC) and laparoscopic CBD exploration under the care of a single consultant surgeon was performed. A total of 592 LCBDEs were performed between September 1992 and January 2011; 325 were transcystic explorations. Of these, 72.5 % were female and 56 % were admitted acutely. Exploration and duct clearance was performed by blind Dormia basket trawling in 63 %. The choledochoscope was utilized in 120 cases (37 %). The 3-mm choledochoscope was used in 66 (55 %) and the 5-mm scope in 54 (45 %). Intrahepatic choledochoscopy was performed in 49 patients (40.8 %). Length of surgery was 40-350 min (median 90 min; standard deviation 49 min). It is technically challenging to perform intrahepatic choledochoscopy with a 3-mm choledochoscope due to its narrow gauge. The more rigid 5-mm scope is thus preferred, but is limited in TCE because its effective use depends on the presence of a dilated cystic duct. Despite the technical limitations of both caliber scopes, we have demonstrated that intrahepatic choledochoscopy during TCE is possible, with each, in 40 % of cases.

Assessment and treatment of choledocholithiasis when endoscopic sphincterotomy is not successful.

Choledocholithiasis exists in approximately 15% of patients with gallstones and is present in 3%-10% of those undergoing cholecystectomy. In this study, we retrospectively analyzed the outcome patients with choledocholithiasis that were managed by open common bile duct (CBD) exploration according to our center's protocol. Endoscopic retrograde cholangiopancreatography (ERCP) was performed for CBD stone clearance. If ERCP and sphincterotomy were not successful, open surgical exploration of CBD was performed with T-tube insertion without routine intraoperative cholangiography (IOC). We studied 1462 patients with choledocholithiasis. ERCP was successful in in 1276 (87.2%) patients. A total of 186 (12.8%) underwent surgery. Of these, 82 (45.2%) had CBD exploration and T-tube insertion without IOC. Choledochoduodenostomy was performed in 82 (44.1%) patients and choledochojejunostomy was performed in 20 (10.8%). Retained stones were found only in 4 cases which were treated by ERCP. ERCP is successful in most cases with choledocholithiasis. If ERCP fails, open exploration of CBD and T-tube insertion, or biliary-enteric anastomosis are acceptable ways for CBD drainage. The rate of retained stone is not more than expected, thus elective IOC is more acceptable than routine IOC. Routine IOC is time-consuming and particularly difficult in elderly patients and emergency conditions.

Prevention of Common Bile Duct Injuries in Laparoscopic Cholecystectomy

Despite advancement in training and technology since its introduction, more than 20 years ago, bile duct injuries continue to be two to three times more common than in open surgery causing significant morbidity and mortality. Hence, a review of the literature present on the internet on bile duct injuries in laparoscopic cholecystectomy was performed to review the causes of biliary injury and methods of prevention of such mishaps. There was a general consensus that careful dissection and correct interpretation of the anatomy avoids the complication of bile duct injury during cholecystectomy. Routine intraoperative cholangiography is associated with a lower incidence and early recognition of bile duct injury. A low threshold to conversion to open approach in case of uncertainty was also advocated.

Single-incision laparoscopic cholecystectomy with routine intraoperative cholangiography and common bile duct exploration via the umbilical port

Laparoscopic cholecystectomy currently is the gold standard technique for gallbladder removal. The use of routine intraoperative cholangiography (IOC) is widely practiced during conventional four-port laparoscopic cholecystectomy (4PLC) to confirm biliary anatomy and allow for immediate management of unexpected choledocholithiasis. Single-incision laparoscopic surgery (SILS) offers a more aesthetic technique for gallbladder removal and has been reported by several groups. However, no series to date have included routine IOC without a separate incision. This study aimed to demonstrate the feasibility of the SILS technique for cholecystectomy with routine IOC (LCIOC) and common bile duct (CBD) exploration as needed via the umbilical port. A database was prospectively completed for a series of 60 consecutive patients undergoing single-incision LCIOC via the umbilical port. Details of the patients, operations, indications, outcomes, and follow-up evaluation were included. Of the 60 patients included in the database, 55 (91.7%) successfully underwent single-incision laparoscopic cholecystectomy (SILC), whereas the remaining five patients required conversion to 4PLC. No patient required conversion to open cholecystectomy (OC). Of the 55 successful SILC patients, 53 (88.3%) successfully received IOCs, 48 of which were normal. The remaining five IOCs demonstrated choledocholithiasis, four of which could be managed laparoscopically without the need for conversion to either 4PLC or OC. One patient required postoperative endoscopic retrograde cholangiopancreatography (ERCP). Complications included four wound infections (7.8%), one incisional hernia (2.0%), and one bile leak (3.2%). The operating time ranged from 35 to 180 min and decreased with experience. This study represents the largest series to date of single-incision laparoscopic cholecystectomies with routine IOC via the umbilical port and is the first study to demonstrate that the laparoscopic management of choledocholithiasis during SILC is feasible.

Primary Closure Following Laparoscopic Common Bile Duct Exploration Combined with Intraoperative Cholangiography and Choledochoscopy

Laparoscopic common bile duct exploration (LCBDE) has become one of the main options for treating choledocholithiasis associated with cholelithiasis. Our objective was to assess the short-term outcomes of patients undergoing laparoscopic primary closure of the common bile duct (CBD) compared with laparoscopic choledochotomy plus T-tube drainage. We retrospectively studied 137 patients undergoing primary closure following LCBDE (group A) compared with 102 cases with laparoscopic choledochotomy plus T-tube drainage (group B) between January 2007 and January 2010. Intraoperative cholangiography (IOC) and choledochoscopy were performed in all patients. Three patients in group A (2.2%) were converted to open surgery and two (2.0%) in group B because of serious adherence. According to routine IOC, unexpected CBD stones were found in 16 cases (6.8%). The duration of the operation in group A was shorter than in group B (92.4 ± 15.2 vs. 125.7± 32.6 min, P < 0.05), as was length of postoperative stay (3.1± 2.4 vs. 5.7± 4.3 days, P < 0.05). Postoperative bile leakage occurred in six patients (4.5%) in group A and four cases (4.0%) in group B; all of the patients recovered after simple drainage without reoperation. Bile peritonitis was seen in one case after T-tube removal. The median follow-up was 26 months. There were no recurrences. Laparoscopic primary closure of the CBD is safe and successful for the management of CBD stones. Application of IOC and choledochoscopy to ensure clearance of the CBD and careful suturing are essential for primary closure.

The role of endoscopy in the management of choledocholithiasis

The role of endoscopy in the management of choledocholithiasis

Lower Rate of Major Bile Duct Injury and Increased Intraoperative Management of Common Bile Duct Stones after Implementation of Routine Intraoperative Cholangiography

Our university medical center is the only center in The Netherlands that has adopted a policy of routine intraoperative cholangiography (IOC) during cholecystectomy. This study aimed to describe the rate of bile duct injury (BDI) and management of common bile duct (CBD) stones before and after implementation of a routine IOC policy. Medical records were reviewed of all patients undergoing cholecystectomy in the 3 years before implementation of routine IOC and 3 years after. Dissection with the goal to achieve the critical view of safety was the standard operative technique during the entire study period. Four hundred and twenty-one patients underwent cholecystectomy with selective IOC and 435 patients with routine IOC. Groups were similar in age, sex, comorbidity, indication for surgery, and surgical approach. IOC was attempted in 5.9% in the selective IOC group and 59.8% in the routine IOC group (p < 0.001). The rate of major BDI was 1.9% in the selective IOC group and 0% in the routine IOC group (p = 0.004). The injuries consisted of 5 type B and 3 type D injuries, according to the Amsterdam classification. The rate of minor BDI did not differ substantially among the groups. More CBD stones were detected in the routine IOC group (4.8% versus 1.0%; p = 0.001) and they were managed intraoperatively more frequently (2.8% versus 0.7%; p = 0.023). There was a trend toward fewer preoperative and postoperative ERCPs and other interventions for CBD stones (19.1% versus 24.2%; p = 0.067). Implementation of routine IOC policy was followed by fewer major BDIs and higher rates of intraoperative CBD stone management.

Cost-Effective Treatment of Patients with Symptomatic Cholelithiasis and Possible Common Bile Duct Stones

Clinicians must choose a treatment strategy for patients with symptomatic cholelithiasis without knowing whether common bile duct (CBD) stones are present. The purpose of this study was to determine the most cost-effective treatment strategy for patients with symptomatic cholelithiasis and possible CBD stones. Our decision model included 5 treatment strategies: laparoscopic cholecystectomy (LC) alone followed by expectant management; preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by LC; LC with intraoperative cholangiography (IOC) ± common bile duct exploration (CBDE); LC followed by postoperative ERCP; and LC with IOC ± postoperative ERCP. The rates of successful completion of diagnostic testing and therapeutic intervention, test characteristics (sensitivity and specificity), morbidity, and mortality for all procedures are from current literature. Hospitalization costs and lengths of stay are from the 2006 National Centers for Medicare and Medicaid Services data. The probability of CBD stones was varied from 0% to 100% and the most cost-effective strategy was determined at each probability. Across the CBD stone probability range of 4% to 100%, LC with IOC ± ERCP was the most cost-effective. If the probability was 0%, LC alone was the most cost-effective. Our model was sensitive to 1 health input: specificity of IOC, and 3 costs: cost of hospitalization for LC with CBDE, cost of hospitalization for LC without CBDE, and cost of LC with IOC. The most cost-effective treatment strategy for the majority of patients with symptomatic cholelithiasis is LC with routine IOC. If stones are detected, CBDE should be forgone and the patient referred for ERCP.

Endoscopic Retrograde Cholangiopancreatography Prior to Laparoscopic Cholecystectomy

To establish the extent to which preoperative endoscopic retrograde cholangiopancreatography (ERCP) is practiced by a representative group of surgeons in the United Kingdom, and to determine its safety and efficacy when compared with a policy of routine intraoperative cholangiography (RIOC), without preoperative ERCP, employed by a single surgical unit. Comparison study between patients undergoing laparoscopic cholecystectomy and patients undergoing laparoscopic cholecystectomy with RIOC. Four hospitals in the Pennine Acute Hospitals NHS Trust in the northwest of England. A total of 1622 patients undergoing laparoscopic cholecystectomy during the period from 2005 to 2007. Of the 1622 patients included in our analysis, 463 patients had an RIOC performed by a single surgical unit. Of the remaining 1159 patients, 188 (16.2%) underwent a preoperative ERCP for suspected common bile duct stones, 107 (56.9%) of whom had negative results. Three patients, 2 of whom had no common bile duct stones, developed post-ERCP pancreatitis. The median duration between ERCP and laparoscopic cholecystectomy was 75 days. Of the 463 patients who underwent an RIOC, 36 (7.8%) had common bile duct stones, 18 (50% of common bile duct stone cases, 3.9% of all 436 RIOC cases) of whom had no preoperative markers for common bile duct stones. There were no bile duct injuries among patients who underwent an RIOC. Preoperative ERCP is widely used in the United Kingdom, but it frequently results in negative findings and therefore is unnecessary. It is associated with significant morbidity, which can be avoided when a policy of RIOC is employed.

Elective Laparoscopic Cholecystectomy without Routine Intraoperative Cholangiography: A Retrospective Analysis of 1101 Consecutive Cases

Laparoscopic cholecystectomy (LC) is today the operation of choice for symptomatic gallstone disease. Before the laparoscopic era intraoperative cholangiography (IOC) was generally considered as a fundamental step in cholecystectomy while nowadays the role of IOC is controversial: is there a need for IOC to specify anatomy of biliary tree in order to avoid bile duct injuries (BDI) and to detect possible common bile duct (CBD) stones or not? We studied retrospectively all the elective LCs done in Turku City Hospital for Surgery during the ten years (1992-2001). Cholecystectomy was performed to 1101 patients, 874 (79%) female and 227 (21%) male patients, mean age 53y (range 15-89). LC was possible in 1022 (93%) cases while 79 (7%) had to be converted to open procedure. The number and severity of bile duct injuries were recorded. The cases with endoscopic retrograde cholangiopancreatography (ERCP) and/or magnetic resonance cholangiopancreatography (MRCP) during the follow-up and the findings in ERCP and MRCP were recorded from patient records and radiological database. IOC was performed in 32 operations (20 in LC and 12 after conversion) and CBD stones were found in seven patients. There were four primary BDIs: two CBD injuries and two minor bile leaks. During a mean follow-up of 72 months (range 36-144) ERCP was performed in 16 and MRCP in three patients. Three patients underwent both MRCP and ERCP. CBD stones were detected in ten patients and a postoperative late CBD stricture was found in one case. According to our data, both the incidence of BDIs (0.5%) and symptomatic postoperative CBD stones (0.9%) remain low without the routine use of IOC.

Routine Intraoperative Cholangiography in Elective Laparoscopic Cholecystectomy

Routine Intraoperative Cholangiography in Elective Laparoscopic Cholecystectomy

Preliminary results of transumbilical single-port laparoscopic cholecystectomy

Single-port laparoscopic cholecystectomy was developed with the aim of reducing the invasiveness of traditional laparoscopy, diminishing postoperative pain and morbidity. The aim of this prospective study was to assess the feasibility and the efficacy of this new approach. Between April and December 2009, a total of 21 patients underwent single-port laparoscopic cholecystectomy for symptomatic gallbladder stone disease. Single surgeon, elective patient, no preoperative diagnosis of common bile duct stone and no previous upper abdominal surgery were the selection criteria chosen for the study. Attempt to reproduce the standard technique (routine intraoperative cholangiography) was considered. Twenty patients (95.2%) successfully completed single-port surgery, and the median operative time was 65 min (range 40-122). Conversion to standard laparoscopic cholecystectomy was required for one patient (4.8%) for a difficult haemostasis. Intraoperative cholangiography was performed for 14 patients (66.7%). Seven patients (33.3%) were discharged on the same day of the operation; median hospital stay was 1 day (range 1-4). No postoperative complications were observed; one patient was reoperated on the same day of surgery because of unexplained abdominal pain and leucocytosis, but relaparoscopy demonstrated no fluid collection. On the 1st postoperative day, median VAS was 3. Most patients declared to be satisfied with the result of the operation and the resulting scar. Transumbilical single-port access cholecystectomy is feasible using standard laparoscopic instruments. It may reduce morbidity, postoperative pain and may offer cosmetic advantages compared with standard laparoscopic approach. However, presently the procedure may be performed only by surgeons with wide experience with this operation through standard laparoscopic access.

Medicolegal claims and intra-operative cholangiography

The vast majority of this piece is sensible and reasonable. Predictably, perhaps inevitably, the authors move into troubled waters when they discuss intra-operative cholangiography (IOC). Is there an issue in gastrointestinal surgery that engenders more controversy or discord? Inevitably, participants in this debate quote evidence to support their own prejudice. It is true that ‘the routine use of IOC has been reported to reduce the incidence of bile duct injuries by clarifying the anatomy’.1 It is also true that numerous national and international series have shown that the use of IOC is not associated with any reduction in the risk or rate of bile duct injury. However, the numbers in these series range between 5 and 70,000 whereas the Flum study already referred to involves 1.5 million procedures. The authors make the statement: ‘an IOC should be used to confirm the anatomy if any doubt exists’. Is there any evidence to support this statement? The Flum paper demonstrates that when the ‘frequent cholangiographer’ (essentially a surgeon who attempts to perform routine IOC) performs a cholan-giogram, a significantly lower incidence of bile duct injury results. This is unarguable. However, the other extremely interesting and seldom mentioned finding of this study is that if the ‘infrequent cholangiographer’ (arbitrarily set at less than 25 % of cases but often much less than this) performs a cholangiogram, the bile duct injury rate, far from decreasing, significantly increases. The authors argue, I believe plausibly, that in this instance the cholangiogram was being done in a ‘difficult’ case. So much for the evidence, what about logic/simple common sense. We have all been faced with a situation where we cannot confidently identify the anatomy in the area of Calot's triangle. Let us analyse what performing a cholangiogram in these circumstances actually means. It involves selecting a bile duct, the identity of which (it is clearly conceded) is uncertain, putting two clips across it and making a hole in it. Is this justifiable or appropriate? I would argue absolutely not. The safe, and therefore the correct, approach in this situation is to dissect the gall-bladder, fundus first, off the liver. This approach can sometimes lead to confident identification of the anatomy at the neck of the gallbladder but in my experience rarely. The sensible course of action is then to stay well clear of Calot's triangle, amputate the gallbladder across Hartmann's pouch, remove any stones and over-sew the remnant It is, of course, possible to do this laparoscopically but many surgeons might prefer to employ open surgery and, if this is the case, they should convert without a moment's hesitation. This approach has served me well for over 20 years, or just under 2500 procedures, with a bile duct injury rate of zero (so far, touch wood!). The advice that cholangiography should be done if the anatomy is unclear is supported by no convincing evidence, is not sensible or logical and should be ignored by all surgeons, particularly those in training.

Management of complicated gallstones: Results of an alternative approach to difficult cholecystectomies

Laparoscopic cholecystectomy (LC) is the gold standard treatment of gallstones. Nevertheless, the incidence of conversion and injuries to the biliary tract is still high in difficult cholecystectomies. In this study we sought to determine how using operative risk predictive scores (PSs) and the Nassar scale to grade the difficulty of LC would optimize the perioperative management of complicated gallstone patients. We also evaluated whether the “fundus-first” approach to LC combined with ultrasonic dissection minimizes the risk of conversion and biliary injury in difficult cholecystectomies, and avoids routine intraoperative cholangiography. A prospective non-randomized study was carried out from 2005 to 2007 including 237 patients referred for gallbladder diseases. All patients were evaluated using an operative risk PS. The LC grade of difficulty was assessed according to Nassar. Diagnostic accuracy, sensitivity, and specificity of PS were calculated. LC in difficult cases was accomplished with a fundus-first approach. Outcome measures included: Conversion rate, bile duct (BD) injury rate, and postoperative complications according to Clavien. In 178 out of 237 patients, a higher risk of conversion and complication was predicted. In 146 out of these 178 cases, intra-operative grading confirmed the difficulty of the procedure. The PS diagnostic accuracy was 0.865, sensitivity was 100%, and specificity 65%. Positive predictive value and negative predictive value were 0.82 and 1, respectively. Conversion rate was 2.7%. Mean operating time and postoperative length of hospital stay were 75 minutes and 3.5 days. Intra-operative cholangiography was necessary in five cases, and one intraoperative biliary complication occurred with an uneventful postoperative course. Overall, postoperative complications were 2.7% with a mortality rate of 0.68% (1 myocardial infarction). Fundus-first LC by ultrasonic dissection is safe and minimizes the risk of conversion and biliary injuries in difficult cases. Difficult cholecystectomies may be predicted preoperatively; in these cases the fundus-first approach and ultrasound dissection may be advised.

‘Critical View of Safety’ as an Alternative to Routine Intraoperative Cholangiography During Laparoscopic Cholecystectomy for Acute Biliary Pathology

IntroductionThe study aims to evaluate the use of “critical view of safety” (CVS) for the prevention of bile duct injuries during laparoscopic cholecystectomy for acute biliary pathology as an alternative to routine intraoperative cholangiography (IOC). MethodsA policy of routine CVS to identify biliary anatomy and selective IOC for patients suspected to have common bile duct (CBD) stone was adopted. Receiver operator curves (ROCs) were used to identify cutoff values predicting CBD stones. ResultsFour hundred forty-seven consecutive, same admission laparoscopic cholecystectomies performed between August 2004 and July 2007 were reviewed. CVS was achieved in 388 (87%) patients. Where CVS was not possible, the operation was completed open. CBD stones were identified in 22/57 patients who underwent selective IOC. Preoperative liver function and CBD diameter were significantly higher in those with CBD stones (P < .001). ROC curve analysis identified preoperative cutoff values of bilirubin (35 μmol/L), alkaline phosphatase (250 IU/L), alanine aminotransferase (240 IU/L), and a CBD diameter of 10 mm, as predictive of CBD stones. No bile duct injuries occurred in this series. ConclusionIn acute biliary pathology, the use of CVS helps clarify the anatomy of Calot's triangle and is a suitable alternative to routine IOC. Selective cholangiography should be employed when preoperative liver function and CBD diameter are above defined thresholds.

Optimal surgical technique, use of intra-operative cholangiography (IOC), and management of acute gallbladder disease: the results of a nation-wide survey in the UK and Ireland

There is debate on optimal techniques that reduce bile duct injury during laparoscopic cholecystectomy (LC). A national survey of Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS) members was carried out to determine current surgical practice for gallstones, including the use of intra-operative cholangiography (IOC) or critical view of safety to reduce the risk of bile duct injury. An anonymous postal survey was sent to all 417 AUGIS members. Data on grade of surgeon, place of work (district general hospital, teaching), subspecialty, number LC per year, use of IOC, critical view of safety, and management of stones detected during surgery were collated. There was a 36% (152/417) response - 134 (88%) from consultant surgeons (36, HPB; 106,OG; 64, DGH; 88, teaching hospital). Of these, 38% performed > 100 LC per year, 36% 50-100 LC per year, and 22% 25-50 LC per year. IOC was routine for 24%; and selective for 72%. Critical view of Calot's triangle was advocated by 82%. Overall, 55% first clip and divide the cystic artery, whereas 41% first clip and divide the cystic duct. Some 39% recommend IOC and 23% pre-operative MRCP if dilated common bile duct (CBD) is noted on pre-operative ultrasound. When bile duct stones are identified on IOC, 61% perform laparoscopic CBD exploration (LCBDE), 25% advise postoperative ERCP, and 13% perform either LCBDE or ERCP. Overall, 88% (n = 134) recommend index cholecystectomy for acute pathology, and this is more likely in a teaching hospital setting (P = 0.003). Laparoscopic CBD exploration was more likely to be performed in university hospitals (P < 0.05). A wide dissection of Calot's triangle to provide a critical view of safety is the technique most commonly recommended by AUGIS surgeons (83%) to minimise risk of bile duct injury, in contrast to 24% that recommend routine IOC. The majority (88%) of AUGIS surgeons advise index admission cholecystectomy for acute gallbladder disease.

Single-Incision Laparoscopic Cholecystectomy: Initial Experience with Critical View of Safety Dissection and Routine Intraoperative Cholangiography

Single-incision laparoscopic cholecystectomy (SILC) is emerging as a potentially less invasive alternative to standard laparoscopic cholecystectomy and natural orifice transluminal endoscopic surgery cholecystectomy. As this technique is more widely used, it is important to maintain well-established practices of the critical view of safety (CVS) dissection and intraoperative cholangiography (IOC). We present our initial experience with SILC using CVS dissection and routine IOC. Fifty-four patients with biliary colic were offered SILC, which was performed through the umbilicus. CVS with photo documentation was attained before clipping and transecting the cystic structures. IOC was done using various needle puncture techniques. Assessment of CVS was carried out by independent surgeon review of operative still photos or videos using a 3-point grading scale: visualization of only 2 ductal structures entering the gallbladder; a clear triangle of Calot; and separation of the base of the gallbladder from the cystic plate. SILC was performed in 54 patients (15 male and 39 female). Six patients required 1 supplementary 3- or 5-mm port. Complete IOC was successful in 50 of 54 patients (92.6%). CVS was achieved at the time of operation in all 54 patients. Photo documentation review confirmed 3 of 3 CVS criteria in 32 (64%) patients, 2 of 3 in 12 patients (24%), 1 of 3 in 3 patients (6%), and 0 in 3 patients (6%). As laparoscopic cholecystectomy becomes less invasive, proven safe dissection techniques should be maintained. Dissection to obtain the CVS should be the goal of every patient and IOC can be accomplished in a high percentage of patients. This approach places patient safety considerations foremost in the evolution of minimally invasive cholecystectomy.

Laparoscopic transcystic bile duct exploration: the treatment of first choice for common bile duct stones

This study was designed to explore the role of transcystic bile duct exploration (TCE) as a first line of treatment for patients with suspected or incidental common bile duct (CBD) stones. A prospective, case-control study of clinically comparable groups of patients who underwent laparoscopic cholecystectomy (LC) alone (n = 1,854) and combined LC/TCE for CBD stones (n = 253) under the care of one surgeon was performed. Other than ultrasonography, no routine preoperative imaging was used; however, we performed routine intraoperative cholangiography on all patients. There was no difference in age (49 +/- 15 vs. 57 +/- 19, p = 0.7), sex (79% vs. 82% females, p = 0.6), and ASA grade (1.9 +/- 1 vs. 1.8 +/- 1, p = 0.7). A larger proportion of the TCE group presented as an emergency (TCE 45% vs. LC alone 27%, p = 0.03) and more often presented with acute biliary pain compared with LC alone (27% vs. 13%, p = 0.02). Although a majority of the patients in the TCE group had clinical or biochemical risk factors for CBD stones (86%), only 27% had suspected stones on preoperative ultrasound. The incidence of jaundice (6% vs. 20%, p = 0.01) was lower in the LC alone group compared with TCE patients. Previous abdominal surgery was noted in 34% patients who underwent LC alone and 30% in LC/TCE (p = 0.06). Significantly there was no difference in open conversion between the two groups (LC alone 0.5% vs. LC/TCE 0.6%, p = 0.07). Comparison of selected outcome parameters for LC versus TCE showed a postoperative hospital stay of 2 (1-14) vs. 2 (1-17) days (p = 0.07), presentation to resolution 1 (1-11) vs. 1 (1-11) weeks (p = 0.07), and morbidity 1.07% vs. 1.2% (p = 0.07). The study advocates single-session laparoscopic cholecystectomy with transcystic CBD exploration as a feasible first choice treatment and the logical next step in the management of patients with CBD stones.

Laparoscopic Cholecystectomy Without Intraoperative Cholangiography: Audit of Long-Term Results

There is no uniform consensus on the utility of routine intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC). In this paper, we present a 10-year retrospective audit of our cases of LC without IOC, performed by a search of readmission cases through our electronic database. Data regarding all patients subjected to LC at our unit in the period January 1996-December 2006 were obtained through our hospital database system. Subsequently, a query was made to ascertain if there were any readmissions to any of our city hospitals, up to December 2006. A total of 1321 patients underwent LC at our unit in the period January 1, 1996-December 31, 2006. The median operating time for LC without IOC was 58 minutes (range, 15-370). The median hospital stay was 2 days (range, 1-30). Postoperative outcome was uneventful in 1250 patients (94.7%). There was no mortality. Grade I and II complications occurred in the remaining 71 patients. Patients were stratified by risk of common bile duct stones (BDSs) according to clinical, ultrasonographic, and serum chemistry data. Patients with suspected BDS underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP) and BDS clearance (142 patients). No patient in our series of LC was readmitted to any of the city hospitals for biliary desease up to 10 years after the operation. Our retrospective audit confirms the safety of LC without routine IOC and the rarity of readmissions for retained BDS and supports the policy of selective IOC.