From the Guidelines
Intraoperative cholangiogram (IOC) is indicated in cases of intraoperative suspicion of bile duct injury, misunderstanding of the biliary anatomy, or inability to see the cystic duct, as well as in patients with acute cholangitis or a history of acute cholangitis. The use of IOC is not recommended as a routine practice due to the lack of significant reduction in complications and bile duct injuries during laparoscopic cholecystectomy 1. However, IOC may be beneficial in specific situations, such as:
- Intraoperative suspicion of bile duct injury
- Misunderstanding of the biliary anatomy
- Inability to see the cystic duct
- Patients with acute cholangitis or a history of acute cholangitis The procedure can help identify bile duct injuries earlier, leading to prompt diagnosis and treatment 1. Alternatively, indocyanine green fluorescence cholangiography (ICG-C) can be used as a useful technique to visualize the biliary tree without the need for X-ray imaging 1. Key benefits of IOC include:
- Reduced risk of bile duct injuries
- Improved understanding of biliary anatomy
- Earlier diagnosis and treatment of bile duct injuries
- Useful in patients with acute cholangitis or a history of acute cholangitis.
From the Research
Indications for Intraoperative Cholangiogram
The indications for an intraoperative cholangiogram (IOC) include:
- Clinical history of jaundice 2
- Pancreatitis 2
- Elevated bilirubin level 2, 3
- Abnormal liver function test results 2, 3
- Increased amylase levels 2
- High lipase level 2
- Dilated common bile duct on preoperative ultrasonography 2, 3
- Anatomic uncertainty during surgery 4, 5
- Preoperative hyperbilirubinemia or ultrasonograph identification of common bile duct dilation 2
- Diagnosis of choledocholithiasis or gallstone pancreatitis 3
- A dilated CBD ≥ 10 mm 3
Selective vs Routine Use of IOC
Studies suggest that the selective use of IOC is helpful in diagnosing and clearing CBD calculi 3, and that preoperative CBD size aids in selecting patients for IOC 3. The selective use of cholangiograms in laparoscopic cholecystectomy will not yield a higher incidence of common bile duct injuries or retained stones compared to routine use 4. However, the routine use of IOC may decrease the rate of CBD injury 6.
Prevention of Bile Duct Injury
IOC can help to avoid bile duct injury by providing profound knowledge concerning the biliary tree, allowing the surgeon to discover whether the patient is at risk for biliary injury, and providing early detection of injury 5. IOC offers an opportunity to prevent error through profound knowledge of biliary diversity and real-time imaging 5.