When should intraoperative cholangiography (IOC) be used during surgical procedures involving the bile ducts, according to the Association of Upper Gastrointestinal Surgeons (AUGIS)?

When to Use Intraoperative Cholangiography During Bile Duct Surgery

Intraoperative cholangiography (IOC) should be used selectively during cholecystectomy—specifically when biliary anatomy cannot be clearly defined, when acute cholecystitis is present or suspected, or when bile duct injury is suspected intraoperatively. 1

Primary Indications for Selective IOC

The World Society of Emergency Surgery provides clear guidance on when IOC should be employed during biliary surgery:

Anatomic Uncertainty

• Use IOC when the hepatocystic triangle cannot be visualized due to inflammation or fibrosis, as this prevents safe identification of biliary structures 1
• Apply IOC when anatomic relationships are distorted by inflammation, adhesions, or anatomic variants to clarify biliary anatomy before proceeding 1
• IOC is particularly valuable when the Critical View of Safety cannot be achieved, as this represents a high-risk scenario for bile duct injury 1

Acute Cholecystitis

• Patients with acute cholecystitis or a history of acute cholecystitis derive the greatest benefit from intraoperative imaging, despite longer operative time 1
• Swedish registry data (51,041 cholecystectomies) demonstrated that IOC reduced bile duct injury risk specifically in patients with concurrent acute cholecystitis (OR 0.44) or history of acute cholecystitis (OR 0.59), but showed no protective effect in uncomplicated gallstone disease 2

Suspected Bile Duct Injury

• IOC is recommended when there is intraoperative suspicion of bile duct injury to enable earlier diagnosis and treatment of recognized injuries 1
• Earlier recognition of bile duct injury significantly improves outcomes, with delayed detection associated with nearly doubled 1-year mortality (HR 1.95) 3

When NOT to Use Routine IOC

Routine IOC is not recommended for low-risk elective cholecystectomy with clear anatomy and normal preoperative studies, as it does not reduce bile duct injury rates or complications 1

• A national U.S. study of 111,815 cholecystectomies found that routine IOC (used in 96% of cases) showed no difference in bile duct injury rates (0.25% vs 0.26%) compared to selective use, but was associated with higher overall complications (7.3% vs 6.8%) and significantly increased costs 4
• In uncomplicated gallstone disease without acute cholecystitis, IOC showed no preventive effect on bile duct injury (OR 0.97) 2

Alternative: Indocyanine Green Fluorescence Cholangiography (ICG-C)

ICG-C is recommended as a useful alternative to traditional IOC for visualizing biliary structures without X-ray imaging 1, 5

• ICG-C provides real-time, noninvasive biliary tract visualization and is particularly useful in acute and chronic gallbladder disease 1, 5
• Meta-analysis of 215 patients found no significant differences between ICG-C and IOC for visualization of the cystic duct, common bile duct, or common hepatic duct 3, 5
• ICG-C demonstrated 74% analyzability rate compared to 70% for traditional IOC-CF in day-case laparoscopic cholecystectomy 6

Algorithmic Decision-Making

Use IOC (or ICG-C) when ANY of the following are present: 1

1. Inability to achieve Critical View of Safety
2. Unclear biliary anatomy (inflammation, fibrosis, adhesions, anatomic variants)
3. Suspected bile duct injury during the procedure
4. Acute cholecystitis (current or history)

Do NOT use routine IOC when: 1

• Low-risk elective cholecystectomy
• Clear anatomy visualized
• Normal preoperative studies
• No acute inflammation

Important Caveats

• Asking the opinion of another surgeon may be an easy, effective, and inexpensive alternative to IOC when anatomy is unclear 3, 5
• IOC does not eliminate the risk of bile duct injury—injuries can still occur and may be detected postoperatively despite IOC being performed 7
• The World Society of Emergency Surgery provides a weak recommendation (GRADE 2B) for selective use of adjuncts, reflecting moderate quality evidence 3
• Conversion to open surgery should be considered when anatomy remains unclear, with conversion rates varying from 23-71% in cases of suspected bile duct injury 3