From the Guidelines
The primary purpose of an intraoperative cholangiogram (IOC) is to recognize bile duct anatomy and choledocholithiasis, particularly in cases of intraoperative suspicion of bile duct injury, misunderstanding of biliary anatomy, or inability to see the cystic duct, and it is not recommended for routine use to reduce bile duct injury rates. According to the 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy 1, IOC is useful in specific situations but not as a routine measure due to its association with longer operative times and potential for misinterpretation. The guidelines suggest that IOC may be beneficial in patients with acute cholecystitis or a history of acute cholecystitis, as well as in cases where there is suspicion of bile duct injury or difficulty understanding the biliary anatomy 1.
Key Points About IOC
- IOC helps in identifying the anatomy of the biliary system and detecting common bile duct stones during surgery.
- It is particularly useful in cases with uncertain biliary anatomy, suspected common bile duct stones, or previous biliary symptoms.
- IOC is not recommended for routine use in all cholecystectomies due to its limitations and potential drawbacks, as highlighted in the guidelines 1.
- The procedure requires fluoroscopy equipment and adds time to the operation, typically around 15 minutes.
Alternative Techniques
- Indocyanine green fluorescence cholangiography (ICG-C) is an alternative, non-invasive technique that can visualize the biliary tree without the need for X-ray imaging, as discussed in the guidelines 1.
- ICG-C has been suggested to be useful in recognizing bile duct anatomy and preventing bile duct injuries, although its routine use is also not yet recommended.
Clinical Decision Making
- The decision to use IOC or other adjuncts like ICG-C should be based on the specific clinical scenario, including the suspicion of bile duct injury, the patient's history, and the surgeon's expertise.
- The use of IOC should be considered on a case-by-case basis, prioritizing its benefits in reducing morbidity and mortality associated with bile duct injuries, while also considering the potential drawbacks and limitations. This approach is supported by the guidelines, which emphasize the importance of selective use of adjuncts for biliary tract visualization during difficult laparoscopic cholecystectomies or when bile duct injury is suspected 1.
From the Research
Purpose of Intraoperative Cholangiogram (IOC)
The purpose of an Intraoperative Cholangiogram (IOC) is to:
- Detect common bile duct stones 2
- Delineate the anatomy of the biliary ducts 2, 3
- Facilitate the dissection of the biliary tract 2
- Avoid injuries to the biliary tract 2, 4, 5
- Identify other abnormalities, such as fistulas, cysts, and tumors of the biliary system 2
- Prevent bile duct lesions 3
- Prevent major biliary injuries 4
Techniques and Methods
Different techniques and methods can be used to perform an IOC, including:
- Transcystic injection of contrast 2
- Cholangiography through the gallbladder 2, 3
- Real-time fluoroscopic intraoperative direct cholangiogram 5
- Near-infrared fluorescent cholangiography (NIRF-C) 6
Benefits and Advantages
The benefits and advantages of using IOC include:
- Improved visualization of the biliary tree 2, 5, 6
- Reduced risk of bile duct injury 4, 5
- Faster procedure time 6
- Ability to identify biliary structures in cases where IOC is unobtainable 6
- Safe and effective alternative to IOC for imaging extrahepatic biliary structures during laparoscopic cholecystectomy 6