Routine intraoperative laparoscopic ultrasonography with selective cholangiography reduces bile duct complications during laparoscopic cholecystectomy

BACKGROUND: Laparoscopic cholecystectomy (LQ is the preferred treatment for gallstone disease, even in many complicated cases. Perhaps the only downsi de to LC is a two- to threefold increase in common bile duct (CBD) injuries compared with open cholecystectomy (OC). Intraoperative cholangiography ma y prevent injuries, but its routine use remains controversial. Our institut ion adopted a policy of selective intraoperative cholangiography in 1993. W hen intraoperative laparoscopic ultrasonography (IOUS) emerged as a viable diagnostic adjunct, it was hypothesized that the routine use of IOUS would facilitate dissection, detect occult choledocholithiasis, and prevent bile duct injuries during LC. STUDY DESIGN: The experience with LC at our university-affiliated teaching hospital was reviewed. Over a 4 1/2-year period (June 1, 1995, to January 3 1, 2000), two surgeons used IOUS routinely during LC (ultrasonography [US] group, n = 248); three other surgeons did not (non-US group, n = 594). We c ompared patient data and outcomes between the two groups. Continuous data a re expressed as mean +/- SEM. RESULTS: During the study period, 842 LCs were attempted. Patient age (37 /1 1 years) and gender (85% female) did not differ between the groups. In t he US group, more patients had acute cholecystitis (p < 0.05). More LCs wer e performed per year by non-US surgeons than US surgeons (45 versus 37). De spite this, A bile duct complications occurred in non-US cases (2.5% overal l): five CBD injuries (0.8%), six bile leaks (1%), and four retained CBD st ones (0.7%). In the subgroup of patients with acute cholecystitis, there we re fewer conversions to OC in US compared with non-US cases (24% versus 36% , p = 0.09). CONCLUSIONS: IOUS is noninvasive, fast, repeatable, and can corroborate rea l-time visualization of the operative field. We have found that LC with IOU S is associated with fewer bile duct complications (CBD injuries, bile leak s, and retained CBD stones) than LC without adjunctive imaging. The success rate of LC in cases of acute cholecystitis is slightly higher when IOUS is used as an aid to dissection. In the absence of definitive prospective dat a, we recommend routine use of IOUS when performing LC, particularly in pat ients with acute cholecystitis. (J Am Coll Surg 2001; 193:272-280. (C) 2001 by the American College of Surgeons).