Ahmad Mirza, MD, Samer Zino, MD, Haitham Qandeel, MBBS, Mk Nassar, Ahmad Nassar. The Monklands District General Hospital, Airdrie, Scotland, UK
Since 1990’s the routine laparoscopic cholecystectomy (LC) has resulted in the decline of routine use of intra-operative cholangiography (IOC). The common bile duct (CBD) stones are being increasingly diagnosed pre-operatively by employing endoscopic retrograde cholangio-pancreaticography (ERCP) and magnetic resonance cholangio-pancreaticography (MRCP). We aimed to evaluate the routine use and clinical benefit of IOC during laparoscopic biliary surgery at a single high volume dedicated biliary surgery unit.
A prospective study of patients undergoing LC and IOC (n=4088) over 20 years was analysed. The pre-operative, intra-operative details and post-operative course was analysed. A standard four port approach (10 mm umbilical, 5 mm epigastric and two 5 mm right upper quadrant). A size 4 French ureteric catheter within an open cannula was used to perform IOC through subcostal port.
There were male 1226 (31%) and female 2862 (69%) patients. A total of emergency 1717 (42%) and elective 2371 (58%)procedures were performed. A total of routine IOC’s 3761 (92%) were performed on routine basis. There were 1672 abnormal cholangiograms, filling defects (992), dilated ducts (545) stricture (22) and abnormal ductal anatomy (24). 1471 patients (36%) had risk factors for CBD stones. IOC identified 858 (21%) with CBD stones. 172 patients (4.2%) with no risk factors for CBD stones were found to have CBD stones. 592 (69%) CBD stones were removed via cystic duct and 266 (31%) were removed through laparoscopic choledochotomy. T-tube were only used in 69 patients who underwent choledochotomy while 197 patients were managed with direct interrupted suture repair of CBD. The routine IOC identified CBD injury in 21 (0.5%) elective and 32 (80%) emergency cases which were managed either with insertion of intraoperative CBD stents or primary repair with cystic duct drainage. Average inhospital stay for patients undergoing LC and common bile duct exploration was 4.9 days.
IOC can be safely and routinely performed with laparoscopic cholecystectomy. It helps to identify CBD stones even in patients with no known CBD stone risk factors, recognition of bile duct injuries and the facilitation of single stage management of CBD stones.