Feasibility of Laparoscopic Intraoperative Cholangiogram in Patients with Intermediate Risk for Choledocholithiasis

BACKGROUND Intra-Operative Cholangiogram (IOC) is a procedure carried out during cholecystectomy with the primary objective of clearly delineating the biliary anatomy. Over decades, routine IOC became selective IOC and now it is being overtaken by less invasive investigations like MRCP and EUS. Role of IOC remains only to intraoperatively confirm or rule out bile duct injury in difficult cases. Laparoscopic IOC is a skilful procedure which requires training and extra added time during laparoscopic cholecystectomy. Once mastered it can be used in many situations for either anatomical reasons or to detect CBD pathology. METHODS All patients getting admitted for laparoscopic cholecystectomy with intermediate risk for choledocholithiasis were enrolled in the study from 2016 to 2019. Procedure was carried out with all necessary consents and precautions. All cases were performed by an experienced GI surgeon and followed up with proper protocol. RESULTS Fifty patients with known intermediate risk for choledocholithiasis underwent laparoscopic cholecystectomy with laparoscopic IOC. Procedure was successfully done in all patients except two, where cystic duct was very thin and cannulation was not possible. Forty-one (82%) patients had deranged liver function test and 9 patients (18%) had history of acute pancreatitis in the past as indications for the procedure. Two patients had dilated CBD (>6 mm) on ultrasound along with deranged liver function tests. An average of 12 minutes was taken to perform the procedure (range: 8 - 15 min). In cases where IOC took longer time was mainly due to technical issues (operability of C-arm). No IOC related complications occurred in any of the patients. Hospital stay was not prolonged in any of the patients due to IOC. None of the patients had any filling defect in CBD. All cases followed till date are asymptomatic. CONCLUSIONS It is a technically feasible procedure that can be performed with limited addition to OT time, minimal failure rate, and complications. All patients with limited criteria for intermediate risk of choledocholithiasis had a normal IOC with no evidence of biliary obstruction in follow up. KEYWORDS Laparoscopic Intraoperative Cholangiogram, Intermediate Risk, CBD Stones

Right Posterior Segmental Hepatic Duct: Role of Intraoperative Cholangiogram to Prevent Extrahepatic Biliary Duct Injuries

Extrahepatic bile ducts constitute a significant anatomic site for surgeons when performing hepatobiliary operations from minor procedure such as cholecystectomy to major operation such as hepatectomy. The challenges for surgeon in performing such cases increase when congenital variance of biliary tree occurs which may lead to unintentional bile duct injuries. We reported a case of a lady who presented with obstructive jaundice secondary to huge distal common bile duct stone. The presence of right posterior segmental hepatic duct, which rarely occurs, was discovered during intraoperative cholangiogram before common bile duct exploration. The operation was successful without incidence of biliary duct injury.