How to perform a laparoscopic intraoperative cholangiogram (lap IOC)?

How to Perform a Laparoscopic Intraoperative Cholangiogram (Lap IOC)

Laparoscopic intraoperative cholangiography (IOC) is a valuable technique for recognizing bile duct anatomy and detecting choledocholithiasis during difficult laparoscopic cholecystectomies, but it should be used selectively rather than routinely. 1

Indications for Lap IOC

• Perform IOC when there is intraoperative suspicion of bile duct injury (BDI), misunderstanding of biliary anatomy, or inability to achieve the critical view of safety (CVS) 1
• Consider IOC in patients with high risk for common bile duct stones (CBDS) 1
• IOC is particularly beneficial in patients with acute cholecystitis or a history of acute cholecystitis 1

Equipment Needed

• C-arm fluoroscopy unit for real-time imaging 2
• Cholangiogram catheter with round-tip stylet 2
• Contrast medium 2
• Graspers and dissectors for cystic duct isolation 3

Step-by-Step Technique for Transcystic IOC

1. Establish the Critical View of Safety first if possible, clearing the lower third of the gallbladder from the liver bed and identifying only two structures entering the gallbladder (cystic duct and cystic artery) 4

2. Isolate and prepare the cystic duct:

   • Dissect the cystic duct adequately to allow for catheter insertion 3
   • Place a clip on the cystic duct close to the gallbladder to prevent contrast reflux 2

3. Create an opening in the cystic duct:

   • Make a small incision in the anterior wall of the cystic duct using microscissors 3
   • Alternatively, use a needle-knife electrocautery for the incision 2

4. Insert the cholangiogram catheter:

   • First insert a round-tip stylet through the sheath to guide it gently through the spiral valves of the cystic duct 2
   • Remove the stylet and insert the cholangiogram catheter smoothly 2
   • Secure the catheter with a clip to prevent dislodgement 3

5. Perform the cholangiogram:

   • Inject contrast medium under fluoroscopic guidance 2
   • Obtain images in multiple projections to visualize the entire biliary tree 2
   • Apply gentle pressure on the gallbladder to advance contrast through the cystic duct if needed 3

6. Interpret the findings:

   • Identify the anatomy of the biliary tree (common bile duct, common hepatic duct, intrahepatic ducts) 3
   • Look for filling defects suggesting stones 5
   • Check for contrast flow into the duodenum 3

7. Complete the procedure:

   • Remove the catheter 2
   • Place clips on the cystic duct and proceed with cholecystectomy 3

Alternative Approach: Gallbladder Cholangiography

• If transcystic approach is difficult, consider performing cholangiography through the gallbladder before starting dissection in the cystic duct area 3
• This technique has shown a success rate of 92% and may be easier and safer than the transcystic technique in certain cases 3
• Use a double-balloon catheter to avoid contrast leak at the puncture site 3

Efficacy and Considerations

• Success rates for IOC range from 88.6% to 96.2% in experienced hands 2, 6
• IOC increases operative time but provides valuable information about biliary anatomy 5
• Alkaline phosphatase (ALP) levels may predict the likelihood of finding filling defects during IOC 5
• While routine use of IOC remains controversial, selective use is supported by high-quality evidence 1, 7

Alternative Imaging Techniques

• Indocyanine Green Fluorescence Cholangiography (ICG-C) is a promising non-invasive alternative that doesn't require X-ray imaging 8
• ICG-C provides real-time imaging of the extrahepatic biliary tract and is quick, safe, and easy to apply 8
• Laparoscopic ultrasound (LUS) has similar sensitivity and specificity to IOC for detecting common bile duct stones 1

Potential Pitfalls and Complications

• Bile duct injury during catheter insertion 1
• False-positive or false-negative findings 6
• Contrast allergic reactions 1
• Failed cannulation of the cystic duct 5

Remember that while IOC is valuable in selected cases, the critical view of safety (CVS) remains the primary approach to minimize the risk of bile duct injuries during laparoscopic cholecystectomy 1, 4.