Laparoscopic Ultrasonography as a Good Alternative to Intraoperative Cholangiography (IOC) during Laparoscopic Cholecystectomy: Results of Prospective Study

Abstract

Intraoperative cholangiography (IOC), used routinely or selectively, is the standard method for bile duct imaging during cholecystectomy. Laparoscopic ultrasonography (LUS) has emerged as a possible, safe and quick alternative. This study examined the evolving use and the performance of these two methods as primary technique for routine bile duct imaging, so as to detect common bile duct stones (CBDS) and to prevent common bile duct injury (CBDI). A prospective database permitted to evaluate the results of the two methods in 968 consecutive cholecystectomies. Nine hundered and twenty five were performed by laparoscopy, 18 (1.9%) by laparotomy and 25 (2.6) necessitated a conversion. The systematic use of the IOC was gradually replaced by a systematic use of the LUS. The success to delineate and evaluate the CBD, the detection of a CBDS, any type of bile duct complication, especially of CBDI, were registered. All the CBDS suspected by LUS were controlled by IOC. The patients were followed during 1 and 6 months. Six hundred and eighty five IOC and 269 LUS were performed. The procedure was technically unsuccessful in 35 IOC (5.1%) (mainly due to difficulty in catheterising the cystic duct) and in 2 LUS (1%) (due to steatosis). Concerning the detection of CBDS, 31 were detected by IOC (4.5%) and 16 by LUS (6%). Five IOC were considered as false positive, 1 as false negative (sensitivity and specificity of 96,9 and 99,2%) and 1 LUS as false positive (sensitivity and specificity of 100 and 99,6%). Five CBDI were detected in the complete seria: 2 during the dissection before the IOC, 1 thermic injury, 1 late stenosis, 1 lateral stenosis by the cystic clip detected by LUS. However none of these CBDI could have been prevented by IOC. In our experience, in this prospective study, LUS has been certainly as effective as IOC as a primary imaging technique for bile duct. It permitted to detect CBDS with a high specificity and sensitivity, and CBDS and was not followed by an increase in CBDI.

Direct Puncture Cholangiography for Clarifying Difficult Anatomy

“…Laparoscopic ultrasound (LUS) is another imaging modality used to detect CBD stones and to verify biliary anatomy, 8 but training and familiarity with the techniques are prerequisites for its adoption. Additionally, it may not provide accurate anatomic details, and the findings might need confirmation with intraoperative cholangiography, resulting in an unnecessary waste of time.…”

Meta-analysis of the diagnostic accuracy of laparoscopic ultrasonography and intraoperative cholangiography in detection of common bile duct stones

“…12,13,15,17,[30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46] There were 4,566 patients in the IOC group and 5,044 in the LUS group.…”

“…Despite this, routine follow-up review took place in only ten studies as a means of excluding clinical events secondary to missed ductal stones. 12,33,[35][36][37][38][39]42,45,46 In the studies that did perform follow-up, no patients were diagnosed subsequently with ductal stones. Although the length of follow-up was limited (range: 6-30 months), these results indicate that true negatives were identified accurately at the time of intraoperative imaging.…”

“…In fact, 16 studies omitted a clear description of their inclusion criteria. 12,13,15,17,30,32,[35][36][37][38][40][41][42][43][44][45] Three studies stated clearly that they had excluded patients at high risk of CBD stones. 31,34,39 Little information was given on the experience of the surgeons performing the procedures for either LUS or IOC.…”

Benign biliary strictures

“…The most common error was accepting an incomplete study as normal, without opacification of the right and left hepatic ducts. Recent studies demonstrate the efficacy of the technique as an alternative to cholangiography (Machi et al, 2009;Hublet et al, 2009), but it is not widely used. They concluded that these injuries stemmed from a misperception that was often so compelling that adjunctive cholangiographic data was likewise misperceived.…”