Is it reasonable to perform an intraoperative cholangiogram during laparoscopic cholecystectomy (lap chole) in a patient with a history of acute cholecystitis, 7 weeks post-cholecystostomy (cholecystostomy tube) drain removal and recent cholangiogram?

From the Guidelines

It is reasonable to perform an intraoperative cholangiogram during laparoscopic cholecystectomy for a patient with a history of acute cholecystitis, 7 weeks post-cholecystostomy drain removal and recent cholangiogram, as it provides real-time assessment of biliary anatomy and can detect any residual stones or abnormalities. This approach is supported by the 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy, which suggest that intraoperative cholangiography (IOC) may be recommended in cases of intraoperative suspicion of bile duct injury, misunderstanding of the biliary anatomy, or even inability to see the critical view of safety (CVS), as well as in patients with acute cholecystitis or a history of acute cholecystitis 1. The guidelines also mention that IOC is useful to recognize bile duct anatomy and choledocholithiasis in cases of intraoperative suspicion of BDI, misunderstanding of biliary anatomy, or inability to see the CVS, but routine use to reduce the BDI rate is not yet recommended 1. However, in patients with a history of acute cholecystitis, intraoperative imaging, although associated with longer operative time, could be of greatest benefit 1. Some of the key points to consider include:

• The timing of 7 weeks post-cholecystostomy is appropriate for definitive surgical management, as it allows for resolution of acute inflammation and creates a safer operative field.
• The recent cholangiogram provides valuable information, but the intraoperative study offers the advantage of evaluating the biliary tree after manipulation of the gallbladder and cystic duct during surgery, which could potentially dislodge stones or reveal anatomical variations not previously identified.
• The use of indocyanine green fluorescence cholangiography (ICG-C) as an alternative to IOC has also been suggested, but its routine use is not yet recommended 1. Overall, the decision to perform an intraoperative cholangiogram should be based on the individual patient's risk factors and the surgeon's judgment, with the goal of maximizing patient safety and preventing bile duct injuries 1.

From the Research

Intraoperative Cholangiogram During Laparoscopic Cholecystectomy

• The use of intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy (LC) is a topic of debate, with some studies suggesting its routine use can improve patient safety and long-term results 2.
• IOC can help delineate biliary tree anatomy, prevent bile duct injury, and image stones in the common bile duct (CBD), making it a valuable alternative to ERCP or MRCP, especially in settings with limited resources 2, 3.
• Studies have shown that IOC is a safe technique, with minor complications related to the procedure being rare and having no consequences for the patients 3, 4.
• The routine use of IOC during LC may not prevent bile duct injuries, but it can minimize the extent of the injury, making it easier to repair without consequences for the patient 3, 5.
• In patients with a history of acute cholecystitis, 7 weeks post-cholecystostomy tube drain removal, and recent cholangiogram, the decision to perform an IOC during LC should be based on individual patient factors and the surgeon's judgment, as there is no clear consensus on the routine use of IOC in this specific scenario.

Considerations for Intraoperative Cholangiogram

• IOC can add an average of 16-28 minutes to the total theatre time, and increase the total charges for the operation 2, 6.
• The selective use of IOC, based on preoperative criteria such as ultrasound, liver function tests, and history of jaundice, or intraoperative anatomical uncertainty, may not yield a higher incidence of common bile duct injuries or retained stones compared to routine use 4.
• IOC can change the operative management in a minority of patients, and can help prevent extension of common bile duct injury, but may not necessarily prevent choledochotomy 4, 6.