What are the indications for intra‑operative cholangiography (IOC) during laparoscopic cholecystectomy according to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)?

Indications for Intraoperative Cholangiography According to SAGES

SAGES makes a conditional recommendation in favor of performing IOC routinely rather than selectively during laparoscopic cholecystectomy, though the strongest evidence supports selective use in specific high-risk scenarios. 1

Primary Indications for Selective IOC

The most compelling indications for IOC during laparoscopic cholecystectomy include:

Anatomic Uncertainty

• When the Critical View of Safety cannot be achieved, IOC should be performed to define biliary anatomy before proceeding with dissection 2, 3
• When the hepatocystic triangle cannot be visualized due to inflammation or fibrosis, IOC helps clarify anatomic relationships 2
• When anatomic relationships are distorted by inflammation, adhesions, or anatomic variants, IOC provides critical anatomic definition 2

Suspected Bile Duct Injury

• IOC is strongly indicated when there is intraoperative suspicion of bile duct injury, enabling earlier diagnosis and treatment of recognized injuries 2, 3
• Early recognition through IOC is the single most important factor for favorable outcomes, as delayed detection significantly increases 1-year mortality (3.9% vs. 1.1%) 3

Acute Cholecystitis

• Patients with acute cholecystitis or a history of acute cholecystitis derive the greatest benefit from intraoperative imaging, despite longer operative time 2
• These patients should undergo cholecystectomy within 48 hours and no more than 10 days from symptom onset 3

Suspected Choledocholithiasis

• IOC is indicated for patients with intermediate to high pre-test probability of common bile duct stones 2
• Preoperative identification of a dilated common bile duct or elevated bilirubin levels are the most reliable predictors and can serve as sole criteria for performing selective IOC 4
• Elevated alkaline phosphatase (ALP) is a significant predictor of filling defects on IOC 5

SAGES Position on Routine vs. Selective IOC

While SAGES makes a conditional recommendation favoring routine IOC over selective use 1, this conflicts with other major guidelines:

• The World Society of Emergency Surgery recommends selective IOC only, not routine use, with a weak recommendation and high-quality evidence (GRADE 2A) 3
• 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 2

Algorithmic Approach to IOC Decision-Making

Perform IOC when ANY of the following are present:

1. Inability to achieve Critical View of Safety 2, 3
2. Unclear biliary anatomy or distorted anatomic relationships 2
3. Suspected bile duct injury intraoperatively 2, 3
4. Acute cholecystitis (current or recent history) 2
5. Preoperative dilated common bile duct on ultrasound 4
6. Preoperative hyperbilirubinemia 4
7. Elevated alkaline phosphatase 5

Important Caveats and Pitfalls

• Do not rely on history of remote jaundice, pancreatitis, or mildly elevated liver enzymes alone, as these result in unnecessary IOCs without reliably predicting choledocholithiasis 4
• IOC should complement, not replace, proper surgical technique and the Critical View of Safety 3
• Never force dissection when CVS cannot be achieved—this is when most injuries occur; instead, perform IOC or consider subtotal cholecystectomy as a bailout procedure 3
• Laparoscopic ultrasound has similar sensitivity and specificity to IOC for detecting common bile duct stones and can be used as an alternative 2

Alternative Imaging Modalities

• Indocyanine green fluorescence cholangiography (ICG-C) is recommended as a useful alternative to traditional IOC for visualizing biliary structures without X-ray imaging 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 2
• However, SAGES makes a conditional recommendation favoring IOC over fluorescence imaging with ICG 1
• Despite its promise, routine use of ICG to reduce bile duct injury rates is not yet recommended (GRADE 2C) 3