What are the indications for intra‑operative cholangiography (IOC) during cholecystectomy?

Indications for Intra-Operative Cholangiogram

Intra-operative cholangiography (IOC) should be performed selectively when biliary anatomy cannot be clearly defined, when there is intraoperative suspicion of bile duct injury, in patients with acute cholecystitis, or when there is intermediate to high pre-test probability of common bile duct stones. 1

Primary Indications for Selective IOC

Anatomic Uncertainty

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

Suspected Bile Duct Injury

• IOC should be performed immediately when bile duct injury is suspected intraoperatively, as this enables earlier diagnosis and treatment of recognized injuries 1
• IOC can prevent extension of minor injuries to major common bile duct injuries by identifying misidentified structures—in documented cases, structures thought to be the cystic duct were revealed by IOC to be the common bile duct itself 2

Acute Cholecystitis

• Patients with acute cholecystitis or a history of acute cholecystitis derive the greatest benefit from intraoperative imaging, despite the procedure adding approximately 28 minutes to operative time 1, 3

Common Bile Duct Stone Detection

• IOC is indicated for patients with intermediate to high pre-test probability of common bile duct stones 1
• The most reliable preoperative predictors are hyperbilirubinemia or ultrasonographic identification of common bile duct dilation—other factors like remote history of jaundice, pancreatitis, or isolated enzyme elevations result in unnecessary IOCs 4
• IOC detects common bile duct stones in approximately 10% of cases, including stones not suspected preoperatively 3, 2

When IOC is NOT Recommended

• 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 in this population 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 1, 5
• 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 1
• ICG cholangiography shows no significant differences compared to IOC for visualization of the cystic duct, common bile duct, or common hepatic duct 5
• ICG should be considered as an adjunct to, not a replacement for, the Critical View of Safety technique 5
• Laparoscopic ultrasound has similar sensitivity and specificity to IOC for detecting common bile duct stones and can be used as an alternative 1

Algorithmic Decision-Making

Use IOC when ANY of the following are present: 1

• Inability to achieve Critical View of Safety
• Unclear biliary anatomy (inflammation, fibrosis, adhesions, anatomic variants)
• Suspected bile duct injury during dissection
• Acute cholecystitis (current or recent)
• Preoperative hyperbilirubinemia
• Dilated common bile duct on preoperative imaging

Important Clinical Considerations

• IOC is successful in approximately 76-82% of attempted cases when performed properly 3, 2
• The procedure adds minimal risk, with only 0.4% minor complications related to IOC itself and no major consequences 2
• IOC may not prevent bile duct injuries, but it minimizes the extent of injury so that it can be repaired easily without consequences for the patient, making it cost-effective 2
• False-positive or false-negative IOC findings can occur, leading to misdiagnosis or delayed diagnosis 6