INTRAOPERATIVE CHOLANGIOGRAPHY FOR LAPAROSCOPIC CHOLECYSTECTOMY

Intraoperative cholangiography in the course of laparoscopic cholecyst ectomy is not only valuable to detect common bile duct stones, but als o to delineate the anatomy of the biliary ducts, facilitate the dissec tion, avoid injuries to the biliary tract and identify other abnormali ties, such as fistulas, cysts and tumors of the biliary system. Most s urgeons use a variation of the transcystic injection of contrast. We d escribe herein a technique of cholangiography through the gallbladder, performed before starting any dissection in the cystic duct area, whi ch has resulted in a rate of 92 percent of adequate cholangiograms and has proved to be easier, by far, and safer than the transcystic techn ique. A comparison was made between 405 instances of open cholecystect omies and 200 laparoscopic cholecystectomies with transcystic cholangi ograms and 105 laparoscopic cholecystectomies with cholangiograms done through the gallbladder. All instances were done for symptomatic chro nic or acute calculous cholecystitis. Satisfactory cholangiograms were obtained in 95 percent of open cholecystectomies and in only 68 perce nt of transcystic laparoscopic attempts. Complications and false-posit ive findings were seen in transcystic laparoscopic procedures in five and six instances, respectively. Cholangiography performed through the gallbladder was 100 percent successful among 73 patients with chronic cholecystitis and in 66 percent of 32 patients with acute calculous c holecystitis. For optimal visualization of the bile ducts, it is essen tial to exert pressure on the gallbladder after die injection of contr ast to advance the contrast through the cystic duct. This is greatly f acilitated by the use of a double-balloon catheter to avoid leak at th e site of the gallbladder puncture.