Overview
Definition:
Cholecystectomy is the surgical removal of the gallbladder
Intraoperative cholangiography (IOC) is an imaging technique performed during cholecystectomy to visualize the biliary tree, specifically the common bile duct (CBD) and its branches, to identify or exclude CBD stones, strictures, or anatomical variations
It is typically performed using X-rays and contrast dye injected into the cystic duct or CBD.
Epidemiology:
Cholelithiasis (gallstones) is a common condition, affecting 10-20% of the adult population worldwide
Cholecystectomy is one of the most frequently performed surgical procedures
CBD stones occur in 5-20% of patients with gallstones undergoing cholecystectomy.
Clinical Significance:
Accurate identification and management of CBD stones are crucial to prevent complications such as cholangitis, pancreatitis, and obstructive jaundice
IOC aids surgeons in making informed decisions regarding CBD exploration, thereby improving patient outcomes and reducing the need for subsequent procedures.
Indications
Indications For Cholecystectomy:
Symptomatic cholelithiasis (biliary colic, acute cholecystitis, choledocholithiasis, gallstone pancreatitis)
Asymptomatic gallstones in specific high-risk populations (e.g., immunocompromised patients, porcelain gallbladder, large stones >3cm, gallstone pancreatitis history).
Indications For Ioc:
Suspicion of common bile duct stones based on preoperative imaging (ultrasound, MRCP) or laboratory findings (elevated bilirubin, alkaline phosphatase)
Unexpected findings during surgery such as dilated CBD or palpable stones
Patients with a history of jaundice or pancreatitis potentially related to gallstones
To delineate anatomy prior to CBD exploration.
Contraindications To Ioc:
Absolute contraindications are rare but may include severe contrast allergy or lack of expertise
Relative contraindications include known bile duct strictures that may not allow contrast passage, or conditions where the risk of radiation or contrast is high.
Preoperative Preparation
History And Physical Examination:
Detailed history of abdominal pain, jaundice, fever, nausea, vomiting
Past surgical history and allergies
Physical exam focusing on abdominal tenderness (Murphy's sign), jaundice, palpable masses, and signs of cholangitis or pancreatitis.
Laboratory Investigations:
Complete blood count (leukocytosis in infection), liver function tests (elevated bilirubin, alkaline phosphatase, GGT suggests biliary obstruction), amylase/lipase (for pancreatitis), coagulation profile, electrolytes, renal function tests.
Imaging:
Abdominal ultrasound is the initial modality of choice for detecting gallstones and CBD dilation
MRCP (Magnetic Resonance Cholangiopancreatography) is highly sensitive and specific for detecting CBD stones and anatomical variations
CT scan can also be used
ERCP (Endoscopic Retrograde Cholangiopancreatography) is both diagnostic and therapeutic but is typically performed preoperatively or postoperatively if IOC is inconclusive or CBD exploration is anticipated.
Anesthesia And Antibiotics:
General anesthesia is typically required
Prophylactic antibiotics (e.g., cephalosporins with metronidazole) are administered to reduce the risk of surgical site infection and cholangitis
Patients with suspected or confirmed CBD stones may receive broader spectrum antibiotics.
Procedure Steps
Technique Selection:
Cholecystectomy can be performed laparoscopically or via open surgery
Laparoscopic cholecystectomy is the preferred approach due to faster recovery and reduced morbidity
IOC can be performed during both.
Access And Exploration:
Laparoscopic access is typically achieved using trocars
The gallbladder is dissected from the liver bed and cystic duct/artery
If IOC is planned, the cystic duct is identified, ligated proximally, and a small incision is made for catheter insertion.
Cholangiography Technique:
A fine catheter is inserted into the cystic duct and advanced into the CBD
Contrast medium is injected slowly under fluoroscopic guidance
Serial X-ray images are obtained to visualize the entire biliary system
Key structures to assess include the cystic duct, CBD, common hepatic duct, intrahepatic ducts, and ampulla of Vater
Potential findings include filling defects (stones), filling defects with irregularity (mucus), CBD dilation (>6-8mm), and anatomical anomalies.
Management Of Findings:
If CBD stones are identified, the surgeon has several options: 1
Proceed with laparoscopic CBD exploration and stone extraction using a choledochoscope or balloon catheter
2
Complete cholecystectomy and defer CBD stone management to postoperative ERCP
3
If open surgery, perform common bile duct exploration
If no stones are found, the cystic duct is ligated, and the surgery is completed.
Completion Of Cholecystectomy:
After IOC and management of CBD findings, the cystic duct and artery are securely ligated
The gallbladder is removed through a port site
The operative field is inspected for bleeding and bile leaks
Hemostasis is ensured, and the abdomen is desufflated and closed
The specimen is sent for histopathology.
Postoperative Care
Monitoring:
Vital signs, urine output, pain control
Close monitoring for signs of complications such as bleeding, bile leak (e.g., abdominal pain, distension, fever, drainage from incision), pancreatitis, cholangitis, or infection.
Pain Management:
Analgesics (opioids, NSAIDs) as needed
Multimodal pain management strategies are employed
Early mobilization is encouraged.
Dietary Advancement:
Patients are typically started on clear liquids postoperatively and advanced to a regular diet as tolerated
Emphasis on hydration.
Discharge Criteria:
Tolerating oral intake, ambulating, adequate pain control with oral analgesics, no signs of infection or complications, and normal bowel function
Follow-up appointment scheduled.
Follow Up:
Routine follow-up with the surgeon usually at 1-2 weeks postoperatively
Review of histopathology report and assessment of recovery
Further management of any residual CBD issues may be planned.
Complications
Early Complications:
Bile leak from cystic duct stump or liver bed
Bleeding
Injury to CBD or hepatic vessels
Pancreatitis
Cholangitis
Wound infection
Retained CBD stones
Pneumonia
Deep vein thrombosis.
Late Complications:
Postcholecystectomy syndrome (persistent abdominal pain, bloating, nausea)
Biliary stricture
Bile duct stones
Gallstone recurrence
Adhesions.
Prevention Strategies:
Meticulous surgical technique, secure ligation of cystic duct and vessels, careful dissection to avoid CBD injury, adequate antibiotic prophylaxis, prompt recognition and management of intraoperative findings, and appropriate postoperative care
Thorough preoperative assessment and imaging to identify high-risk patients for IOC.
Key Points
Exam Focus:
Indications for IOC
Interpretation of IOC findings (filling defects, dilation, anatomical variations)
Management options for CBD stones identified on IOC
Potential complications of IOC and cholecystectomy
Differences between laparoscopic and open CBD exploration.
Clinical Pearls:
Always confirm IOC catheter position before contrast injection to avoid extravasation
If uncertain about CBD anatomy, consider intraoperative ultrasound or consult with a radiologist/gastroenterologist
A negative IOC does not entirely exclude small retained stones.
Common Mistakes:
Failure to perform IOC in suspected CBD stones
Inadequate visualization of the biliary tree during IOC
Incomplete clearance of CBD stones
Misinterpretation of IOC images
Undertreating or overlooking anatomical variations.