Routine intraoperative laparoscopic ultrasonography with selective cholangiography reduces bile duct complications during laparoscopic cholecystectomy

Abstract

Background: Laparoscopic cholecystectomy (LC) is the preferred treatment for gallstone disease, even in many complicated cases. Perhaps the only downside to LC is a two- to threefold increase in common bile duct (CBD) injuries compared with open cholecystectomy (OC). Intraoperative cholangiography may prevent inj uries, but its routine use remains controversial. Our institution adopted a policy of selective intraoperative cholangiography in 1993. When intraoperative laparoscopic ultrasonography (IOUS) emerged as a viable diagnostic adjunct, it was hypothesized that the routine use of IOUS would facilitate dissection, detect occult choledocholithiasis, and prevent bile duct injuries during LC.

Study design: The experience with LC at our university-affiliated teaching hospital was reviewed. Over a 4 1/2-year period (June 1, 1995, to January 31, 2000), two surgeons used IOUS routinely during LC (ultrasonography [US] group, n = 248); three other surgeons did not (non-US group, n = 594). We compared patient data and outcomes between the two groups. Continuous, data are expressed as mean +/- SEM.

Results: During the study period, 842 LCs were attempted. Patient age (37+/-1 years) and gender (85% female) did not differ between the groups. In the US group, more patients had acute cholecystitis (p < 0.05). More LCs were performed per year by non-US surgeons than US surgeons (45 versus 37). Despite this, all bile duct complications occurred in non-US cases (2.5% overall): five CBD injuries (0.8%), six bile leaks (1%), and four retained CBD stones (0.7%). In the subgroup of patients with acute cholecystitis, there were fewer conversions to OC in US compared with non-US cases (24% versus 36%, p = 0.09).

Conclusions: IOUS is noninvasive, fast, repeatable, and can corroborate real-time visualization of the operative field. We have found that LC with IOUS is associated with fewer bile duct complications (CBD injuries, bile leaks, and retained CBD stones) than LC without adjunctive imaging. The success rate of LC in cases of acute cholecystitis is slightly higher when IOUS is used as an aid to dissection. In the absence of definitive prospective data, we recommend routine use of IOUS when performing LC, particularly in patients with acute cholecystitis.