Technique and results of routine dynamic cholangiography during 528 consecutive laparoscopic cholecystectomies

With the advent of laparoscopic cholecystectomy a trend toward more extensive preoperative diagnostic study of the biliary tree by intravenous cholangiography or ERCP has been observed. However, both exams have technical limitations and are not without risk. We report our experience with 500 consecutive routine dynamic intraoperative cholangiographies during laparoscopic cholecystectomy, 97% of which were successful. No lesions from cholangiography were observed. In ten patients clips on the cystic artery appeared on intraoperative cholangiogram to be too close to the hepatic duct and were removed. Anomalies of surgical importance were discovered in 11 patients (2.3%). Unsuspected stones were found in 18 cases (3.7%) and suspected stones confirmed in 12 (2.4%). In our experience routine dynamic intraoperative cholangiography provided important information in 51 cases out of 500 (10.2%). We conclude that routine dynamic intraoperative cholangiography is extremely useful for safer laparoscopic cholecystectomy and cost containment. © 1994 Springer-Verlag New York Inc

[Intraoperative digital cholangiography during laparoscopic cholecystectomy interventions].

In the last years, laparoscopic cholecystectomy has become the method of choice in the surgical treatment of gallbladder stones. Recently, the same laparoscopic approach has been used to remove choledochus stones. This surgical procedure needs the accurate intraoperative study of the biliary tree with diagnostic imaging modalities to better define the anatomy of the biliary ducts and the possible presence of choledochus stones. To this purpose, transcutaneous and endolaparoscopic US with dedicated probes and intraoperative cholangiography can be performed. In this study, we performed 30 laparoscopic cholecystectomies during which all the patients were submitted to intraoperative cholangiography with a digital fluoroscopic unit. The maneuvers for catheter insertion in the cystic duct and the examination as a whole took 3 to 5 minutes. Intraoperative cholangiography demonstrated choledochus stones in 3 patients, while preoperative US detected them in 2 patients only. In 8 cases the dynamic study, carried out with digital image acquisition, allowed to refer the biliary duct filling defects to artifacts caused by the presence of air bubbles. In conclusion, intraoperative cholangiography, also during endolaparoscopic cholecystectomy, plays a major role in the surgical assessment of the biliary tree. When the procedure was performed with a digital fluoroscopic unit, its diagnostic accuracy was higher and the images on the TV monitor were better visualized

Ruolo dell'ecografia intraoperatoria nella colecistectomia laparoscopica

On the basis of recent technological improvements, the laparoscopic approach has become the method of choice during cholecystectomy. This surgical procedure, however, needs that cholangiography be performed simultaneously to better define the anatomy of the biliary ducts and the possible presence of choledochus stones. The use of intraoperative US during cholecystectomy is nowadays advocated for the unquestionable advantages offered by this technique--i.e., its non-invasiveness, high spatial resolution and no need of contrast agent administration. In this study, we examined 30 patients with cholelithiasis who underwent laparoscopic cholecystectomy and were submitted to endolaparoscopic US besides routine intraoperative cholangiography. In all cases, both techniques allowed optimal visualization of the biliary tree, clearly demonstrating choledochus stones in 2 cases. Intraoperative US proved to be more accurate in two cases. In one case which was positive at intraoperative cholangiography, the method allowed the biliary duct filling defect to be referred to an artifact caused by the presence of an air bubble. In another case, the lack of opacification of the hepatic ducts at cholangiography was referred, after US, to extrinsic gallbladder compression. US also allowed the adjacent parenchymal organs, such as the liver and the head of pancreas, to be studied. A limitation of this technique was represented by the difficult assessment of the choledochus in the patients with anatomical abnormalities or adhesions of the intestinal loops of the upper abdomen. In conclusion, endolaparoscopic US proved to be a reliable technique in the intraoperative study of the biliary ducts and can be considered as a procedure complementary to intraoperative cholangiography

Single-stage laparoscopic surgery of cholelithiasis and choledocholithiasis in 268 unselected consecutive patients

AIMS: The introduction of laparoscopic cholecystectomy (LC) has modified the treatment of gallstones and common bile duct (CBD) stones. Aim of this prospective study was to evaluate the results of single stage laparoscopic management of gallstones and CBD stones. PATIENT AND METHODS: From January 1991 to October 1999, CBD stones were present at intraoperative cholangiography in 268 patients (pts) (169 females, 99 males, mean age 55.6 years, range 12-94 years) out of 2693 undergoing LC (10%) for gallstones. CBD stones were unsuspected in 123 (45.9%) and suspected in 145 (54.1%). RESULTS: CBD exploration was successful in 264 cases (98.5%) (transcystic 164, choledochotomy 100). Four pts were converted to open surgery (1.5%). Retained stones in 15 patients (5.7%), were treated by ERCP/ES (6 pts) and by percutaneous endoscopic/fluoroscopic stone removal (6 pts). Spontaneous stones passage occurred in 2 pts, one patient is waiting for treatment. Major morbidities were hemoperitoneum (4 cases) and cystic duct bile leakage (3 cases). One high risk patient died postoperatively. Recurrent stones were observed in 5 pts (1.9%), at 1, 4, 8, 18, 26 months respectively after T-tube removal, and were treated by ERCP/ES in 4 cases. Spontaneous stone passage occurred in 1 case. CONCLUSIONS: LC and CBD exploration has shown to be safe and feasible with low morbidity and mortality. The rationale of this approach is to solve two problems during the same procedure, limiting the role of endoscopic sphincterotomy to the treatment of residual ductal stones