Related Articles

Background

To determine if cholecystectomy can be performed satisfactorily without the use of adjunctive intraoperative cholangiography (IOC), we planned a retrospective analysis at a Canadian university teaching hospital.

Methods

General operative morbidity and mortality (in particular, occurrences and complications of missed choledocholithiasis and reoperations for same, and occurrences of bile duct injuries and bile leaks) were noted and analyzed for a consecutive series of cholecystectomies from a single practice, carried out without IOC.

Main results

In general, choledocholithiasis could be identified and treated before the operation; missed cases were infrequent and were treatable without reoperation. No major injuries to the bile duct were encountered.

Conclusions

IOC appears to be optional with cholecystectomy; cholecystectomy can be performed without IOC safely in the defined setting, without related major complications from missed choledocholithiasis or excess occurrence of bile-duct injury.

INTRODUCTION

Common bile duct (CBD) stones can cause serious morbidity or mortality, and evidence for them should be sought in all patients with symptomatic gallstones undergoing cholecystectomy. Routine intra-operative cholangiography (IOC) involves a large commitment of time and resources, so a policy of selective cholangiography was adopted. This study prospectively evaluated the policy of selective cholangiography for patients suspected of having choledocholithiasis, and aimed to identify the factors most likely to predict the presence of CBD stones positively.

PATIENTS AND METHODS

Data from 501 consecutive patients undergoing laparoscopic cholecystectomy (LC) for symptomatic gallstones, of whom 166 underwent IOC for suspected CBD stones, were prospectively collected. Suspicion of choledocholithiasis was based upon: (i) deranged liver function tests (past or present); (ii) history of jaundice (past or present) or acute pancreatitis; (iii) a dilated CBD or demonstration of CBD stones on imaging; or (iv) a combination of these factors. Patient demographics, intra-operative findings, complications and clinical outcomes were recorded.

RESULTS

Sixty-four cholangiograms were positive (39%). All indications for cholangiogram yielded positive results. Current jaundice yielded the highest positive predictive value (PPV; 86%). A dilated CBD on pre-operative imaging gave a PPV of 45% for CBD calculi; a history of pancreatitis produced a 26% PPV for CBD calculi. Patients with the presence of several factors suggestive of CBD stones yielded higher numbers of positive cholangiograms. Of the 64 patients having a laparoscopic common bile duct exploration (LCBDE), four (6%) required endoscopic retrograde cholangiopancreatography (ERCP) for retained stones (94% successful surgical clearance of the common bile duct) and one (2%) for a bile leak. Of the 335 patients undergoing LC alone, three (0.9%) re-presented with a retained stone, requiring intervention. There were 12 (7%) requiring conversion to open operation.

CONCLUSIONS

A selective policy for intra-operative cholangiography yields acceptably high positive results. Pre-operatively, asymptomatic bile duct stones rarely present following LC; thus, routine imaging of the biliary tree for occult calculi can safely be avoided. Therefore, a rationing approach to the use of intra-operative imaging based on the pre-operative indicators presented in this paper, successfully identifies those patients with bile duct stones requiring exploration. Laparoscopic bile duct exploration, performed by an experienced laparoscopic surgeon, is a safe and effective method of clearing the bile duct of calculi, with minimal complications, avoiding the necessity for an additional intervention and prolonged hospital stay.

Background

Correct assessment of biliary anatomy can be documented by photographs showing the “critical view of safety” (CVS) but also by intraoperative cholangiography (IOC).

Methods

Photographs 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.

Results

The 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).

Conclusion

In 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.

INTRODUCTION: Magnetic resonance cholangiopancreatography (MRCP) is a safe and sensitive investigation for the imaging of common bile duct pathology. When used to exclude common bile duct (CBD) stones, MRCP may obviate the need for intra-operative cholangiogram (IOC). In this prospective study, we looked at the single centre results of patients who underwent cholecystectomy with IOC following pre-operative MRCP. PATIENTS AND METHODS: Over a period of 18 months, 69 patients (24 male and 45 female; mean age 59 years [range, 19-86 years]) were investigated by MRCP prior to cholecystectomy. All patients underwent IOC. Inclusion criteria for MRCP consisted of derangement of liver function tests and/or history of jaundice in cases of ultrasound-proven cholelithiasis. RESULTS: Sixteen patients had suspected stones or filling defects on MRCP; all but two of these were confirmed to be stones on IOC. In only one patient was a stone visualised on IOC and not seen on MRCP. CONCLUSION: MRCP may be the only pre-operative investigation needed for exclusion of CBD stones, obviating the necessity for IOC.

Background

Clinicians must choose a treatment strategy for patients with symptomatic cholelithiasis without knowing whether common bile duct (CBD) stones are present. The purpose of this study was to determine the most cost-effective treatment strategy for patients with symptomatic cholelithiasis and possible CBD stones.

Study Design

Our decision model included five treatment strategies: (1) laparoscopic cholecystectomy (LC) alone followed by expectant management, (2) preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by LC, (3) LC with intraoperative cholangiography (IOC) ± common bile duct exploration (CBDE), (4) LC followed by postoperative ERCP, and (5) LC with IOC ± postoperative ERCP. The rates of successful completion of diagnostic testing and therapeutic intervention, test characteristics (sensitivity and specificity), morbidity, and mortality for all procedures are from current literature. Hospitalization costs and lengths of stay are from the 2006 National CMS data. The probability of CBD stones was varied from 0% to 100% and the most cost-effective strategy was determined at each probability.

Results

Across the CBD stone probability range of 4% to 100%, LC with IOC ± ERCP was the most cost-effective. If the probability was 0%, LC alone was the most cost-effective. Our model was sensitive to one health input: specificity of IOC, and three costs: cost of hospitalization for LC with CBDE, cost of hospitalization for LC without CBDE, and cost of LC with IOC.

Conclusions

The most cost-effective treatment strategy for the majority of patients with symptomatic cholelithiasis is LC with routine IOC. If stones are detected, CBDE should be forgone and the patient referred for ERCP.

OBJECTIVES: There is little data on the natural history of asymptomatic bile duct stones and hence there is uncertainty on the management of asymptomatic bile duct stones discovered incidentally at the time of laparoscopic cholecystectomy. We retrospectively reviewed a group of patients who had previously underwent laparoscopic cholecystectomy, but who did not have a pre-operative suspicion of intra-ductal stones, to determine if any biliary complications had subsequently developed. A group of patients who had no pre-operative suspicion of intra-ductal stones, but routinely underwent intraoperative cholangiogram (IOC) at time of cholecystectomy, served as the control group. METHODS: A telephone questionnaire was completed by each patient's family practitioner in 59 of 79 (75%) patients who underwent laparoscopic cholecystectomy. In the remaining 20 patients additional information was obtained from hospital records and from the central services agency (CSA). These patients had no pre-operative suspicion of bile duct stones and therefore did not undergo an IOC or ERCP. The control group (73 patients) had no pre-operative suspicion of bile duct stones but had a routine IOC performed to define the biliary anatomy. RESULTS: 59 patients were followed up for an average of 57 months (range 30-78 months) after laparoscopic cholecystectomy. None of these patients developed pancreatitis, jaundice, deranged liver function tests (LFT's), or required ERCP or other biliary intervention. In the additional 20 patients where no information was available from the family practitioner, 11 patients had follow up appointments with no documentation of biliary complications or abnormal LFT's. 19 of 20 patients were traceable through the CSA and were all alive. Only 1 patient was untraceable and therefore unknown if biliary complications had developed. In the control group, 4 of 73 (6%) patients had intraductal stones detected and extracted. Thus the prevalence of asymptomatic bile duct stones during the time of cholecystectomy in our population was 6%. CONCLUSIONS: Asymptomatic bile duct stones discovered at the time of cholecystectomy do not appear to cause any biliary complications over a 5-year follow up. Incidental bile duct stones found in patients undergoing laparoscopic cholecystectomy may not need to be removed.

Introduction

Intraoperative cholangiograms (IOCs) may increase cost, surgical time, and radiation exposure to staff and patients. We introduce the application of passive infrared (IR) imaging to intraoperative cholangiography as a feasible alternative to traditional fluoroscopic IOCs.

Methods

A porcine model was used in which the gallbladder, cystic duct, CBD, and duodenum were exposed and an 18 gauge angiocatheter was inserted into the cystic duct. IR emission was detected using a digital IR camera (Lockheed Martin Inc., Goleta, CA) positioned at 30–60 cm above the abdomen. IR images were taken in real-time (~1/sec) during infusion of room temperature saline. A thermoplastic polymer stone was then inserted into the CBD. Once the artificial stone was placed, room temperature saline was again injected. A standard single shot renograffin IOC was obtained to confirm the obstruction. The experiment was concluded by a lateral 2mm CBD injury immediately proximal to the duodenum followed by infusion of room temperature saline.

Results

A total of 6 pigs were used. Baseline IR imaging was able to capture a visible temperature decrease, outlining the lumen of the CBD. With injection of room temperature saline, a decrease in temperature was visualized as a dark area representing flow from the CBD to the duodenum. After placement of the synthetic stone, real-time IR images displayed the injected bolus being slowed by the obstruction. The obstruction was correlated with fluroscopic IOCs. Finally, after partial transection of the CBD, the IR camera visualized saline flowing from the site of injury and out into the peritoneal cavity.

Conclusions

CBD anatomy, obstruction, and injury can be clearly visualized with an IR camera. Intraoperative IR imaging is an emerging modality already being utilized in several surgical fields. Ultimately, the integration of IR and laparoscopic technology will be necessary to make IR technology important in laparoscopic cholecystectomy.

INTRODUCTION

The causes and outcomes of medicolegal claims following laparoscopic cholecystectomy were evaluated.

SUBJECTS AND METHODS

A retrospective analysis of the experience of a consultant surgeon acting as an expert witness within the UK and Ireland (1990–2007).

RESULTS

A total of 151 claims were referred for an opinion. Sixty-three related to bile duct injuries and four followed major vascular injury. Bowel injury resulted in 17 claims. A postoperative biliary leak not associated with a bile duct injury was responsible for 25 claims. Other reasons for claims included spilled gallstones, port-site herniae, haemorrhage and other recognised complications associated with laparoscopic cholecystectomy. Twelve of the claims are on-going, two went to trial, 79 (52%) were settled out of court and 58 (38%) were discontinued after the claimants were advised that they were unlikely to win their case. Disclosed settlement amounts are reported.

CONCLUSIONS

Bile duct and major vascular injuries are almost indefensible. The delay in diagnosis and (mis)management of other recognised complications following laparoscopic cholecystectomy have also led to a significant number of successful medicolegal claims.

Background

Accidental injury to the common bile duct is a rare but serious complication of laparoscopic cholecystectomy. Accurate visualization of the biliary ducts may prevent or detect injuries early. Conventional X-Ray cholangiography is often used and can reduce the severity of injury when correctly interpreted. However, it may be useful to have an imaging method that could provide real-time extra-hepatic bile duct visualization without changing the field of view from the laparoscope. The purpose of this study was to use a new NIR fluorescent agent that is rapidly excreted via the biliary route in pre-clinical models to evaluate intra-operative real time near infrared fluorescent cholangiography (NIRFC).

Methods

To investigate probe function and excretion, a lipophilic near infrared fluorescent agent with hepatobiliary excretion was injected intravenously into one group of C57/BL6 control mice and four groups of C57/BL6 mice with the following experimentally-induced conditions: a) chronic biliary obstruction, b) acute biliary obstruction c) bile duct perforation and e) choledocholithiasis, respectively. The biliary system was imaged intravitally for one hour using near-infrared fluorescence (NIRF) with an intra-operative small animal imaging system (excitation 649 nm, emission 675 nm).

Results

The extra hepatic ducts and extra-luminal bile were clearly visible due to the robust fluorescence of the excreted fluorochrome. Twenty-five minutes after intravenous injection, the target-to-background ratio peaked at 6.40 ± 0.83 but was clearly visible for ~ sixty minutes. The agent facilitated rapid identification of biliary obstruction and bile duct perforation. Implanted beads simulating choledocholithiasis were promptly identifiable within the common bile duct lumen.

Conclusions

NIRF agents with hepatobiliary excretion may be used intra-operatively to visualize extra hepatic biliary anatomy and physiology. Used in conjunction with laparoscopic imaging technologies this should enhance hepatobiliary surgery.

Laparoscopic cholecystectomy (LC) using an electrosurgery energy source was successfully performed in 59 (95%) out of 62 selected patients. The procedures were performed by different surgical teams at Trakya University, Medical Fakulty, in the department of General Surgery and the Karl-Franzens-University School of Medicine, in the department of General Surgery. Cholangiography was routine at Karl Franzens University and selective at Trakya University. Laparoscopic intraoperative cholangiography (IOC) was performed in 48 (81.3%) patients, and open IOC was performed in 3 patients. Two patients had common duct stones; one of which was unsuspected preoperatively. These cases underwent endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic papillotomy (EP). One patient had a choledocal tumor, unsuspected preoperatively. Anatomical anomalies were not identified. Cholangiography could not be performed in one case in which there was no suspected pathology. ERCP was performed on one patient 30 days after being discharged because of acute cholangitis. In this case, residual stones were identified in the choledocus. Four patients underwent open cholecystectomy because of tumor, unidentified cystic duct or common bile duct pathology that could not be visualized on the cholangiogram. Our study suggests that cholangiography performed via the cystic duct before any structures are divided can prevent the most serious complication of laparoscopic cholecystectomy – common duct injury. We recommend that cholangiography be attempted on all patients undergoing LC.

Iatrogenic bile-duct injury post-laparoscopic cholecystectomy remains a major serious complication with unpredictable long-term results. We present a patient who underwent laparoscopic cholecystectomy for gallstones, in which the biliary injury was recognized intraoperatively. The surgical procedure was converted to an open one. The first surgeon repaired the injury over a T-tube without recognizing the anatomy and type of the biliary lesion, which led to an unusual biliary mal-repair. Immediately postoperatively, the abdominal drain brought a large amount of bile. A T-tube cholangiogram was performed. Despite the contrast medium leaking through the abdominal drain, the mal-repair was unrecognized. The patient was referred to our hospital for biliary leak. Ultrasound and cholangiography was repeated, which showed an unanatomical repair (right to left hepatic duct anastomosis over the T-tube), with evidence of contrast medium coming out through the abdominal drain. Eventually the patient was subjected to a definitive surgical treatment. The biliary continuity was re-established by a Roux-en-Y hepatico-jejunostomy, over transanastomotic external biliary stents. The patient is now doing well 4 years after the second surgical procedure. In reviewing the literature, we found a similar type of injury but we did not find a similar surgical mal-repair. We propose an algorithm for the treatment of early and late biliary injuries.

Intraoperative cholangiography was successfully performed in 1,000 out of 1,006 attempts in 1019 consecutive cholecystectomies. There were 783 chronic, 95 acute, 61 fibrotic, 27 gangrenous and 40 cases of hydrops of the gallbladder in those laparoscopic cholecystectomies performed. Unsuspected common duct stones were identified in 5% of the patients. There were no injuries resulting from intra-operative cholangiography performed via the cystic duct. In this large series, routine cholangiography was thought to be helpful in the prevention of common bile duct injuries and the establishment of abnormal anatomy. In non-acute cholecystitis, intraoperative cholangiography is necessary due to the importance of abnormal anatomy verification. The technique of laparoscopic cholecystectomy differs greatly from that of open technique, and, therefore, routine intraoperative cholangiography is strongly advised.

The place of cholangiography in laparoscopic cholecystectomy is debatable. This retrospective study reviews the outcome of 2061 patients operated upon for symptomatic gallstones in two district general hospitals. Intraoperative cholangiography was not used because all patients were submitted to a policy of selective preoperative investigation of the extrahepatic ducts. The conversion rate to open cholecystectomy was 3.1% and 88% of patients were discharged home within 48 h of surgery. No major duct injuries occurred and only 12 patients have presented with a proven retained stone after operation (0.7%). This policy of preoperative investigation and treatment for extrahepatic bile duct stones without intraoperative cholangiography has been employed in over 2000 patients and is at least as safe as published results using routine intraoperative cholangiography.

Objectives To determine whether the routine use of intraoperative cholangiography can improve survival from complications related to bile duct injuries.

Design Population based cohort study.

Setting Prospectively collected data from the Swedish national registry of gallstone surgery and endoscopic retrograde cholangiopancreatography, GallRiks. Multivariate analysis done by Cox regression.

Population All cholecystectomies recorded in GallRiks between 1 May 2005 and 31 December 2010.

Main outcome measures Evidence of bile duct injury, rate of intended use of intraoperative cholangiography, and rate of survival after cholecytectomy.

Results During the study, 51 041 cholecystectomies were registered in GallRiks and 747 (1.5%) iatrogenic bile duct injuries identified. Patients with bile duct injuries had an impaired survival compared with those without injury (mortality at one year 3.9% v 1.1%). Kaplan-Meier analysis showed that early detection of a bile duct injury, during the primary operation, improved survival. The intention to use intraoperative cholangiography reduced the risk of death after cholecystectomy by 62% (hazard ratio 0.38 (95% confidence interval 0.31 to 0.46)).

Conclusions The high incidence of bile duct injury recorded is probably from GallRiks’ ability to detect the entire range of injury severities, from minor ductal lesions to complete transections of major ducts. Patients with bile duct injury during cholecystectomy had impaired survival, and early detection of the injury improved survival. The intention to perform an intraoperative cholangiography reduced the risk of death after cholecystectomy.

Objective:

We conducted a retrospective 4-year study of patients undergoing laparoscopic cholecystectomy at a freestanding ambulatory surgery center. Data on rates of hospital admission, conversion to open surgery, bile duct injury, postoperative bile leakage, and incidence of choledocholithiasis were analyzed. The success rate for dynamic fluoroscopic intraoperative cholangiography was computed, and outpatient laparoscopic common bile duct exploration and anesthetic management were reviewed.

Methods:

Patient charts from the ambulatory surgery center, office, and hospital were reviewed over a 4-year period commencing in October 1999. All cases were performed by 1 of 3 surgeons who are experienced with outpatient laparoscopic cholecystectomy and practice routine dynamic fluoroscopic intraoperative cholangiography.

Results:

A total of 338 laparoscopic cholecystectomies were performed. Dynamic fluoroscopic intraoperative cholangiography was successfully performed in 89% (n=302). No instances of bile duct injury or conversions to open surgery were reported. A 0.89% (n =3) incidence of postoperative bile leak occurred. Six patients were admitted for inpatient care for a rate of 1.78%. Choledocholithiasis occurred in 2.0% and was managed successfully in the ambulatory setting.

Conclusion:

Laparoscopic cholecystectomy can be adapted to the freestanding ambulatory surgery environment with very high standards of care and very low complication rates.

The Mirizzi syndrome refers to benign obstruction of the common hepatic duct by a stone impacted within the neck or cystic duct of the gallbladder, which causes extrinsic compression of the common hepatic duct and obstructive jaundice. Although a rare cause of obstructive jaundice, it remains a clinically and surgically challenging problem. Five patients with the Mirizzi syndrome were culled from over 9000 patients undergoing operation for gallstone disease. The management of these patients was detailed. Diagnosis requires a high index of clinical suspicion but can be confirmed with the use of ultrasonography and percutaneous transhepatic cholangiography. Cholecystectomy and common duct exploration are essential components of operative therapy, but additional procedures to repair non-circumferential bile duct defects or strictures must be anticipated.

Background

Bile duct injury (BDI) is a dreaded complication of cholecystectomy, often caused by misinterpretation of biliary anatomy. To prevent BDI, techniques have been developed for intraoperative assessment of bile duct anatomy. This article reviews the evidence for the different techniques and discusses their strengths and weaknesses in terms of efficacy, ease, and cost-effectiveness.

Method

PubMed was searched from January 1980 through December 2009 for articles concerning bile duct visualization techniques for prevention of BDI during laparoscopic cholecystectomy.

Results

Nine techniques were identified. The critical-view-of-safety approach, indirectly establishing biliary anatomy, is accepted by most guidelines and commentaries as the surgical technique of choice to minimize BDI risk. Intraoperative cholangiography is associated with lower BDI risk (OR 0.67, CI 0.61–0.75). However, it incurs extra costs, prolongs the operative procedure, and may be experienced as cumbersome. An established reliable alternative is laparoscopic ultrasound, but its longer learning curve limits widespread implementation. Easier to perform are cholecystocholangiography and dye cholangiography, but these yield poor-quality images. Light cholangiography, requiring retrograde insertion of an optical fiber into the common bile duct, is too unwieldy for routine use. Experimental techniques are passive infrared cholangiography, hyperspectral cholangiography, and near-infrared fluorescence cholangiography. The latter two are performed noninvasively and provide real-time images. Quantitative data in patients are necessary to further evaluate these techniques.

Conclusions

The critical-view-of-safety approach should be used during laparoscopic cholecystectomy. Intraoperative cholangiography or laparoscopic ultrasound is recommended to be performed routinely. Hyperspectral cholangiography and near-infrared fluorescence cholangiography are promising novel techniques to prevent BDI and thus increase patient safety.

Surgical exploration of the common bile duct for gallstones is a common operation but carries a high residual stone rate. Conventional techniques for exploring the bile ducts are blind procedures. The surgeon cannot see what he is doing. Also there has been no reliable method for a postexploratory check of the bile ducts before closure, usually around a T-tube. Operative choledochoscopy allows the surgeon to see stones in the duct, may aid the removal of stones and provides visual postexploratory checks that the common bile duct and the hepatic ducts are clear, that papilla is patent and that no stone is left behind before closure. A personal series of 150 patients had operative choledochoscopy using a flexible fibreoptic choledochoscope. If there was a clear indication on preoperative investigations that the ducts should be explored, an operative cholangiogram was omitted and the choledochoscope used as the exploring instrument. In 127 patients with a diagnosis of gallstone disease, choledochoscopy was used at the primary operation. In 12 patients choledochoscopy was used at a secondary operation for recurrent gallstone disease, and 11 patients had malignant obstruction of the biliary tract. In 70 of the 127 patients, gallstones were found and extracted using the choledochoscope. In 53 patients the ducts were clear, and in 4, other lesions were found: 3 papillomas and one polycystic disease. One hundred and six of the patients had the common bile duct closed primarily with no T-tube drainage. There was no increase in complications and no deaths associated with choledochoscopy or primary closure of the common bile duct.(ABSTRACT TRUNCATED AT 250 WORDS)

Images

Background

Cholecystectomy has been the treatment of choice for symptomatic gallstones, but remains the greatest source of post-operative biliary injuries. Laparoscopic approach has been recently preferred because of short hospitalisation and low morbidity but has an higher incidence of biliary leakages and bile duct injuries than open one due to a technical error or misinterpretation of the anatomy. Even open cholecystectomy presents a small number of complications especially if it was performed in urgency. Hemobilia is one of the most common cause of upper gastrointestinal bleeding from the biliary ducts into the gastrointestinal tract due to trauma, advent of invasive procedures such as percutaneous liver biopsy, transhepatic cholangiography, and biliary drainage.

Methods

We report here a case of massive hemobilia in a 60-year-old man who underwent an urgent open cholecystectomy and a subsequent placement of a transhepatic biliary drainage.

Conclusion

The management of these complications enclose endoscopic, percutaneous and surgical therapies. After a diagnosis of biliary fistula, it's most important to assess the adequacy of bile drainage to determine a controlled fistula and to avoid bile collection and peritonitis. Transarterial embolization is the first line of intervention to stop hemobilia while surgical intervention should be considered if embolization fails or is contraindicated.

Operative cholangiography is for most surgeons a routine part of every cholecystectomy. Computerised digital subtraction angiography was adapted for operative cholangiography using a portable machine. After cannulation of the cystic duct the background image was subtracted before injecting contrast. Only the contrast within the bile duct appears on the monitor and resolution is high. A permanent record was made on 10 X 10 cm spot films. Eighteen pre-exploratory cholangiograms were performed using this method. In 12 no stones were demonstrated on digital subtraction cholangiography (DSC), nor were there clinical indications of common bile duct stones. These patients underwent cholecystectomy only. Stones were demonstrated on DSC in 3 patients and all had stones at exploration of the common bile duct (CBD). Three patients had no stones demonstrated on DSC but were explored on clinical grounds. No stones were found. Postoperative T-tube cholangiograms confirmed the absence of stones in 5 patients. A retained stone was present in one patient who had not had a postexploratory examination at operation and was not related to the use of this cholangiographic technique. DSC combines the benefits of image intensification and still radiography and has been accurate in both predicting and excluding common bile duct stones.

Images

A total of 487 cholecystectomies were performed at one hospital over a 44-month period by surgeons who differed considerably in the frequency with which they performed operative cholangiography. There were no differences in the frequency or severity of postoperative complications or recurrent symptoms between patients who did and those who did not undergo operative cholangiography; nor were any differences demonstrable between patients operated on by different surgeons. Although it is established that operative cholangiography will demonstrate otherwise unsuspected common bile duct stones in some patients, it has not yet been clearly proved that these stones would cause later complications if left undisturbed. The clinical advantages of operative cholangiography are not sufficiently clear to preclude their assessment by prospective controlled studies involving large numbers of patients.

This study notes that the development of single-incision laparoscopic surgery is not without risk and that obtaining the critical view in appropriately selected patients is essential for safe single-incision laparoscopic surgery.

Background:

The advancement and development of laparoscopic cholecystectomy revolutionized surgery and case management. Many procedures are routinely performed laparoscopically. Single incision laparoscopic surgery has been introduced with the hope of further reduction of scarring and possibly procedural pain. With no established technique for this procedure, the safety of single incision laparoscopic cholecystectomy has not been determined.

Methods and Results:

A 30-year-old man underwent single incision laparoscopic cholecystectomy for symptomatic cholelithiasis at an outside hospital. The operation was uneventful, and the patient was discharged home. The patient returned to the Emergency Department 4 days postoperatively, and a bile duct injury was diagnosed. A percutaneous drain was placed, and the patient was transferred to the Hepato-Pancreato-Biliary (HPB) service of a tertiary care center for definitive care. A delayed repair approach was used to allow the inflammation around the porta to decrease. Six weeks after injury, the patient underwent Roux-en-Y hepaticojejunostomy. The patient did well postoperatively.

Conclusion:

Although single incision laparoscopic surgery will play a prominent role in the future, its development and application are not without risks as demonstrated from this case. It is imperative that surgeons better define the surgical approach to achieve the critical view and select appropriate patients for single incision laparoscopic cholecystectomy.

Northern Ireland has one of the largest surgical training programmes in the United Kingdom. The surgical trainees' assessment of the quality of training provided has been collated prospectively since 1983, and provides a useful insight into the strengths and weaknesses of the programme, as well as the training value of individual posts. The overall quality of clinical training in surgery was considered to be well above average, but some registrars felt that supervision of operative surgery could be improved. Clinical research was considered to be of average quality in the teaching hospitals but below average in district general hospitals. In the current climate of restriction of the number of training posts in general surgery, the views of the trainees should not be neglected in assessing which posts are best suited for training.

Options for managing the common bile duct during laparoscopic cholecystectomy include routine peroperative cholangiography and selected preoperative endoscopic retrograde cholangiopancreatography (ERCP). The use of these methods was reviewed in 350 patients with symptomatic gall stones referred for laparoscopic cholecystectomy. Unit A (n = 114) performed routine cystic duct cholangiography but undertook preoperative ERCP in patients at very high risk of duct stones only; unit B (n = 236) performed selected preoperative ERCP on the basis of known risk factors for duct stones. The detection rate for common bile duct stones was similar for units A and B (16% v 20%). In unit A, five of seven patients who had preoperative ERCP had duct stones. Operative cholangiography was technically successful in 90% of patients and duct stones were confidently identified in 13, one of whom went on to immediate open duct exploration. Postoperative ERCP identified duct stones in only four patients, indicating spontaneous passage in eight. In unit B, preoperative ERCP was undertaken in 76 of 236 (32%) patients and duct stones were identified in 47 (20%). Duct clearance was successful in 42 (18%) but failed in five (2%), necessitating elective open duct exploration. Both protocols for imaging the common bile duct worked well and yielded satisfactory short term results.

Modern operative treatment of diseases of the bile passages requires the use of x-ray visualization of the biliary tract before, after and during operation. Nearly every surgeon uses x-ray study of the biliary tract before operation and it is widespread practice to carry out such study after operations in which a tube has been placed in the bile passages. However, there is a remarkable aversion to operative cholangiography.

The usual reasons for avoiding operative cholangiography are unfamiliarity, inertia, concern over complications of the technique, and the feeling that it is unnecessary or wasteful of surgeon's time and patient's money. Yet the results of operative cholangiograms compare favorably with those obtained with the more customary x-ray studies of the bile ducts carried out after operation, at a time when the information gained is much less valuable in avoiding additional operations and in contributing to a smooth and rapid convalescence.