Documenting correct assessment of biliary anatomy during laparoscopic cholecystectomy

Abstract

BackgroundCorrect assessment of biliary anatomy can be documented by photographs showing the “critical view of safety” (CVS) but also by intraoperative cholangiography (IOC).MethodsPhotographs of the CVS and IOC images for 63 patients were presented to three expert observers in a random and blinded fashion. The observers answered questions pertaining to whether the biliary anatomy had been conclusively documented.ResultsThe CVS photographs were judged to be “conclusive” in 27%, “probable” in 35%, and “inconclusive” in 38% of the cases. The IOC images performed better and were judged to be “conclusive” in 57%, “probable” in 25%, and “inconclusive” in 18% of the cases (P < 0.001 compared with the photographs). The observers indicated that they would feel comfortable transecting the cystic duct based on the CVS photographs in 52% of the cases and based on the IOC images in 73% of the cases (P = 0.004). The interobserver agreement was moderate for both methods (kappa values, 0.4–0.5). For patients with a history of cholecystitis, both the CVS photographs and the IOC images were less frequently judged to be sufficient for transection of the cystic duct (P = 0.006 and 0.017, respectively).ConclusionIn this series, IOC was superior to photographs of the CVS for documentation of the biliary anatomy during laparoscopic cholecystectomy. However, both methods were judged to be conclusive only for a limited proportion of patients, especially in the case of cholecystitis. This study highlights that documenting assessment of the biliary anatomy is not as straightforward as it seems and that protocols are necessary, especially if the images may be used for medicolegal purposes. Documentation of the biliary anatomy should be addressed during training courses for laparoscopic surgery.

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

“…The incorrect interpretation of cholangiograms is probably the most important of these considerations [62,63], and a recent evaluation of IOC found that correct biliary anatomy could only be conclusively documented in 57 % of cases [64], a feat that is rendered even more difficult in the presence of cholecystitis. Conflicting reports exist about the usefulness of IOC for the identification of biliary anatomy when there is significant scarring or inflammation in the triangle of Calot [61,64]. Adequate resolution of the anatomy is imperative so that injuries can be identified to permit successful repair.…”

Laparoscopic Intraoperative Cholangiography Interpretation by Surgeons versus Radiologists, A Comparative Study and Review of 200 Cholangiographies

“…The use of IOC has a high sensitivity of 93.9%, a specificity of 89.7%, and positive and negative predictive values of 98.7% and 97.6%, respectively, in the detection of ductal stones. The reported incidence of false-positive cholangiograms still ranges from 2% to 16% [5]. False-positive cholangiograms commonly result from misinterpretation of filling defects and artifacts (air bubbles), which have the radiological appearance of stones, resulting in unnecessary choledochotomy.…”

“…This seems evident for IOC because it is part of the radiology studies in the patient medical file. Documentation of the biliary anatomy can be used by the surgeon to substantiate measures taken to ensure safety [5]. Although surgical practice has largely settled on selective instead of routine use of operative cholangiography, if properly interpreted, cholangiography can limit the frequency and severity of bile duct injuries [6].…”

Quality of Operative Notes for Laparoscopic Cholecystectomy: Are They Useful?

“…[8] This is further documented either in the written note, intraoperative cholangiogram, or a photograph or video, if possible. [9,10] All patients in this study had paper based operative orders with boxes for individual pieces of information. Patient particulars and information deemed necessary as per RCS Eng Guidelines are rarely left unfilled.…”