Role of Intraoperative Cholangiography in UK Guidance
Intraoperative cholangiography (IOC) should be used selectively during laparoscopic cholecystectomy—specifically when biliary anatomy cannot be clearly defined, when bile duct injury is suspected, or during difficult cases—but routine use in all cholecystectomies is not recommended. 1, 2
Primary Indications for Selective IOC
The World Society of Emergency Surgery provides clear guidance on when IOC should be employed during bile duct surgery:
Specific Clinical Scenarios Requiring IOC
Inability to achieve Critical View of Safety: When the hepatocystic triangle cannot be visualized due to inflammation, fibrosis, or adhesions, IOC should be performed to define biliary anatomy before proceeding with ductal transection 1, 2
Suspected bile duct injury: IOC is recommended when there is intraoperative suspicion of injury to enable earlier diagnosis and treatment, as early recognition significantly impacts outcomes (patients with delayed detection have nearly doubled 1-year mortality: HR 1.95) 1, 2
Acute cholecystitis: Patients with acute or previous acute cholecystitis derive the greatest benefit from intraoperative imaging despite longer operative time 2
Distorted anatomic relationships: When inflammation, adhesions, or anatomic variants obscure normal biliary anatomy 2
Evidence Against Routine Use
Routine IOC in low-risk elective cholecystectomy with clear anatomy is not recommended, as it does not reduce bile duct injury rates or complications in straightforward cases 1, 2. The World Society of Emergency Surgery provides a weak recommendation with high quality evidence (GRADE 2A) that IOC is useful to recognize bile duct anatomy and choledocholithiasis in cases of intraoperative suspicion, but routine use to reduce BDI rate is not yet recommended 1.
Alternative Imaging Modality
Indocyanine green fluorescence cholangiography (ICG-C) serves as a useful alternative to traditional IOC for visualizing biliary structures without X-ray imaging 3, 2. ICG-C provides real-time, noninvasive biliary tract visualization and is particularly useful in acute and chronic gallbladder disease when traditional IOC cannot be used 3, 2. However, similar to IOC, routine use of ICG-C to reduce bile duct injury rates is not yet recommended (GRADE 2C) 1, 3.
Clinical Impact on Outcomes
The timing of bile duct injury recognition critically affects patient outcomes. Data demonstrate that:
Early intraoperative detection matters: Patients with injuries detected perioperatively have similar 1-year survival to those without injury, while delayed detection nearly doubles mortality risk 1
IOC can prevent extension of injury: When minor injuries are identified early through IOC, they can be repaired immediately without consequences, preventing progression to major common bile duct injuries 4
Detection rates vary widely: Only 25-92% of bile duct injuries are diagnosed intraoperatively, highlighting the importance of selective use in high-risk scenarios 1
Practical Algorithm for IOC Decision-Making
Use IOC when any of the following are present 2:
- Inability to achieve Critical View of Safety
- Unclear biliary anatomy
- Suspected bile duct injury
- Acute cholecystitis
- Anatomic variants or distorted anatomy
Do not use routine IOC for straightforward elective cholecystectomy with clear anatomy and normal preoperative studies 1, 2.
Important Caveats
Consulting another surgeon may be an easy, effective, and inexpensive alternative to IOC when anatomy is unclear or injury is suspected 3. This simple intervention should not be overlooked as it may provide immediate clarification without additional procedural time or equipment.
IOC should be considered an adjunct to, not a replacement for, the Critical View of Safety technique, which remains the primary method to minimize bile duct injury risk 3. When Critical View of Safety cannot be achieved, consider bailout procedures like subtotal cholecystectomy rather than forcing dissection 5.