Intraoperative cholangiography in the laparoscopic cholecystectomy era: why are we still debating?

F. Ausania 0 1 2 L. R. Holmes 0 1 2 F. Ausania 0 1 2 S. Iype 0 1 2 P. Ricci 0 1 2 S. A. White 0 1 2 Hepato (Liver) 0 1 2 0 S. Iype Upper GI Surgery, Ipswich Hospital , Ipswich, UK 1 F. Ausania P. Ricci Forensic Medicine, Magna Graecia University , Catanzaro, Italy 2 F. Ausania (&) L. R. Holmes S. A. White HPB Surgery, Freeman Hospital , Newcastle Upon Tyne NE77DN, UK Laparoscopic cholecystectomy is now one of the most frequently performed abdominal surgical procedures in the world. The most common major complication is bile duct injury, which can have catastrophic repercussions for patients and it has been suggested that intraoperative cholangiography may reduce the rate of bile duct injury. Whether this procedure should be performed routinely is still an active subject of debate. We discuss the available evidence and likely implications for the future. - The first laparoscopic cholecystectomy (LC) was performed in September 1985 by Erich Muhe [1]. Although the surgical community was initially unconvinced about the significance of this new technique, it is now the most frequently performed abdominal surgical procedure, and one of the most common operations in Europe and the United States [2]. Morbidity has been reported as 24 %, whereas the incidence of major complications that require urgent operative management is much lower [2, 3]. The most common major complication is bile duct injury (BDI), with published rates as high as 1.4 %, although the literature more commonly reports incidence as 0.150.6 %, approximately one per 200 procedures [29]. In contrast, the incidence of BDI after open cholecystectomy (OC) is reported as 0.10.3 %, an equivalent nearer to one per 500 cases [10, 11]. Traditionally, surgeons opt for operations with lower complication rates, and the learning curve was one of the arguments to account for the increased incidence of BDIs during LC [12]. However, further publications have reported that this incidence remains higher even when learning curve is accounted for [4, 13, 14], even in light of technological advances that have improved visualization and instrumentation [1418]. Despite this evidence, LC remains the treatment of choice for symptomatic gallstones, a fact most likely attributable to the benefits of less postoperative pain, shorter hospital stay, better cosmetic result, and increased patient satisfaction [12, 1922]. In fact, the number of cholecystectomies in the United Kingdom has nearly doubled during the past decade (Fig. 1). Bile duct injury: mechanism, classification, and consequences Davidoff et al. described classical laparoscopic BDI as misinterpretation of the common bile duct (CBD) or hepatic duct, as the cystic duct, resulting in clipping and division [23]. Several mechanisms for laparoscopic ductal injury can be identified, including tenting and diathermy injuries [7]. Dissection of the hilum of the liver can result in injury of more proximal hepatic ducts; nonetheless, the causes leading to BDI often are multifactorial. These causes include excessive bleeding, poor visualization of the field, inflammation, poor illumination, lack of awareness Fig. 1 Number of total cholecystectomies in the United Kingdom (Source: Hospital Episode Statistics) about the orientation of bile duct anatomy, anatomical abnormalities, and surgical incompetence. There are several classifications for BDI. Bismuths classification (Type IV) of BDI/stricture precluded the advent of LC but helped surgeons to choose the type of repair and correlated well with outcome [24, 25]. McMahon et al. [26] then further subdivided the type of BDI into laceration, transection, or excision, while retaining Bismuths classification to grade the level of the stricture. Minor and major injuries also were distinguished for the purposes of management; minor required a simple suture repair and/or insertion of a T-tube, whereas a hepaticojejunostomy was recommended to treat a major injury [26]. Strasbergs classification (Type AE) is a comprehensive modification of Bismuths classification that includes various other types of laparoscopic extrahepatic BDIs [11]. Various other systems have since been proposed by Bergman et al. [27], Neuhaus et al. [28], Csendes et al. [29], Stewart et al. [30], and Lau et al. [31] in an effort to describe all possible lesions (Table 1). Recently Cannon et al. [32] have reported criteria to aid in predicting the financial cost of a particular insult and when referral to a tertiary hepatobiliary center is appropriate. BDI causes serious consequences for the patient, which is compounded by any delay in the recognition of an insult or if a repair is attempted by an inexperienced surgeon [33]. Several authors have reported alarming outcomes for BDI repair, and in some series, mortality and morbidity for biliodigestive reconstruction after injury are as high as 8.6 % and 42 % respectively [34]. Even in the event of a successful repair, subsequent morbidity is significant and the sequelae include symptomatic adhesions, recurrent cholangitis, abscess, strictures, secondary biliary cirrhosis, and chronic liver disease [3, 3540]. In extreme cases, a liver transplant may be required as a direct result of BDI complications [4143]. As well as these physical complications, BDI also has been shown to impact a patients quality of life and life expectancy significantly, often even after successful repair [44, 45]. The poor outcome after BDI often is determined by the severity and level of the injury during LC. Ludwig et al. found that the most common lesions are type C and D according to the Neuhaus classification, injuries that often can require a biliodigestive anastomosis, which confers significant morbidity and mortality [9]. Lillemoe et al. [46] also compared BDIs sustained during LC versus OC and found that the injuries associated with LC tended to be more complex, with more than 60 % classified as Bismuth 3 or higher compared with only 40 % of this severity as a result of OC. Role of intraoperative cholangiogram (IOC): a literature overview In the past many attempts have been made to reduce the rate of BDI. Among these, IOC is probably the most commonly used, as well as the most debated. This technique, originally described by Mirizzi in 1931 [47], involves endoscopic cannulation of the cystic duct to visualize the bile duct. This allows the identification of any bile duct stones or preexisting anatomic abnormalities, as well as highlighting iatrogenic injuries that may have occurred [2]. IOC was historically utilized in open procedures to aid CBD stone detection and its routine use was debated long before the birth of LC [48]. However, IOC during LC provides the additional benefit of providing a road map for operative dissection. Some institutions use IOC routinely to identify CBD stones, provide extra evidence for anatomical decisions during dissection, training purposes, and to highlight biliary injury should it occur. The selective use of IO (...truncated)