Year : 2021 Month : January Volume : 8 Issue : 2 Page : 108-114.
Adithya G.K.1, Satya Prakash Jindal2, Varun Madaan3, Vachan Hukkeri4, Rigved Gupta5, Vivek Tandon6, Deepak Govil7
1, 2, 3, 4, 5, 6, 7 Department of Surgical Gastroenterology, Indraprastha Apollo Hospital, New Delhi, India.
Dr. Adithya G. K.,
Department of GI Surgery,
Indraprastha Apollo Hospital,
Mathura road, Sarita Vihar,
New Delhi - 110076, India.
Email : firstname.lastname@example.org
Intraoperative cholangiogram (IOC) is a procedure carried out during cholecystectomy with the primary objective to clearly delineate the biliary anatomy. The history of intraoperative cholangiography (well written by Mac Fadyen1) began in 1918 where Reich first reported the delineation of the anatomy of the biliary tree by using bismuth and petrolatum to identify a biliary fistula.2 The first series of IOC was reported by Mirizzi in 1931. He recommended the routine use of IOC in order to identify unsuspected common bile duct (CBD) injuries.3 Later Hickens and colleagues also advocated its use in 1936.4 Since then, surgeons observed an improvement in the results of common bile duct exploration (CBDE) if it was based on filling defects seen on IOC rather than the clinical criteria for CBD exploration commonly used at that time which were history of jaundice, cholangitis or pancreatitis; multiple gallbladder stones; or a dilated common bile duct (CBD). With the use of an IOC, stones were found twice as often during CBDE, and also there was a marked decrease in the frequency of performing CBDE during cholecystectomy.5-8 the initial IOC’s were performed using static films and that required an average of 20 - 30 minutes to complete the procedure that often had to be repeated.1
In current day practice the role of intra operative cholangiogram during routine laparoscopic cholecystectomy remains controversial. Disadvantages of routine IOC include increased cost, operating time, need for technical expertise and false positive results leading to unnecessary CBDE or ERCP.9 The introduction of MRCP has contributed to the decline in the diagnostic evaluation of patients with suspected CBD stones with ERCP and other modalities. A study conducted in 1999 by Varghese and colleagues showed that MRCP has a sensitivity, specificity, and diagnostic accuracy of 91%, 98%, and 97%, respectively, for the detection of CBD stones. And also, CBD stones were confirmed in all patients by direct cholangiographic methods including ERCP, IOC, and percutaneous transhepatic cholangiography indicating that diagnostic accuracy of MRCP is similar to that of direct cholangiography in the diagnosis of CBD stones.10
Endoscopic ultrasound (EUS) can also be used to evaluate the CBD to identify calculi. Studies have compared the accuracy of EUS to US, CT and ERCP for detecting CBD stones and showed a sensitivity of EUS ranging from 88% - 97%, with a specificity of 96% - 100%. This result is comparable to ERCP and avoids the complications of pancreatitis, cholangitis and radiation exposure. The role of EUS, however, is yet to be established especially when cost and availability of less invasive modalities such as MRCP are much handier.11
Requirement of extra skills and time to conduct IOC has shifted many surgeons from IOC to MRCP. Given its increasing availability and accuracy the European Association of Laparoscopic Surgeons now consider MRCP to be the standard diagnostic test for patients with an intermediate probability of CBD stones.12
In Indian situation laparoscopic surgery especially cholecystectomy is available in most of the small peripheral centres. However availability and especially interpretation of MRCP and EUS are not widely available. An important additional advantage is that IOC allows for the evaluation of CBD by surgeon himself/herself allowing for a dynamic evaluation of contrast flowing from CBD to duodenum.
Keeping this in mind in our study we have aimed to evaluate the feasibility of laparoscopic IOC in intermediate category of patients for CBD stones for the complete evaluation of CBD highlighting its applicability in our unique healthcare scenario where laparoscopic cholecystectomy is done in small peripheral centers without access to MRCP/EUS.
We performed a prospective cohort study in the department of GI surgery, Indraprastha Apollo hospital, Sarita Vihar, Delhi, India with a sample size of 50. All patients getting admitted for laparoscopic cholecystectomy falling within intermediate risk group for CBD stones (according to SAGES criteria) in all cholelithiasis patients from June 2016 to June 2018 in our hospital were included in the study. Data collection started with an informed consent for the particular study. Brief history and examination of patients especially for history of jaundice and history of pancreatitis in the past, history of hypersensitivity to any contrast agents were noted. Liver function reports containing parameters of interest like bilirubin, alkaline phosphatase, gamma - glutamyl transpeptidase, transaminases were noted down. Patients were selected based on the inclusion criteria. Ultrasonography report of abdomen to note status of gall bladder, CBD and liver was collected. Laparoscopic intraoperative cholangiogram was performed as explained below using instruments like, C - arm, flexible catheter (No. 6 ureteric catheter), laparoscopic instruments used for cholecystectomy, dye (Urografin in 1:2 dilution with saline), monitor, lead aprons, glove piece, 18G needle, saline.
Inclusion criteria included 1) Cholelithiasis patients with LFT report showing mildly elevated bilirubin (1.8 - 4 mg%), serum alkaline phosphatase and or/or gamma GTP (more than once, but less than twice). 2) Ultrasound report revealing dilated CBD (>6 mm) 3) Recent past history of jaundice or pancreatitis. Exclusion criteria included, 1) Acute cholangitis, 2) Patients with recognized liver conditions deranging liver function tests, 3) Patients falling in low risk category.
Pneumoperitoneum is created using Veress needle and laparoscopic ports are placed according to laparoscopic cholecystectomy requirement. Calot’s triangle is dissected to demonstrate cystic artery and cystic duct. Cystic artery is clipped and divided if easily accessible or else can be dealt with later on. Cystic duct is dissected circumferentially taking down the small fibrous and fatty strands. Nothing but the duct should be visible. Duct is milked towards gall bladder with Maryland forceps to push any stone lying in cystic duct and a distal clip (size may be 300 or 400 titanium clip) is applied. Small ductotomy is made in cystic duct proximal to distal clip transversely. Bile should be visible pouring out of cystic duct. Now the ureteric catheter (5 or 6F) is passed through subcostal 5 mm port as shown in the picture (Figure 1). Fundal grasper is moved to neck of the gall bladder and catheter is pushed in to CBD though cystic duct ductotomy site using Maryland forceps passed through epigastric port. Saline syringe is connected to the catheter and saline is pushed drop by drop during this period. After confirming its position in CBD, saline is pushed into catheter to make sure catheter is lying freely inside. Now a clip is placed over cystic duct including the catheter to fix its position (Figure 2). Clip is tightened only to hold the catheter in place with an eye on the continuously running saline from the syringe.
All the instruments from table or body are removed and forceps is kept over abdomen to guide the direction. C - arm is brought over the operating table and its position is fixed. Dye is loaded to a syringe in 1:2 dilution of dye and saline. All the air removed from syringe and injected slowly through the catheter. Fluorographs are recoded continuously and dynamic flow of dye into CBD and then to duodenum is checked (Figure 3). Patient position is changed with little head low and right side up to fill up both the hepatic ducts. Ductal patency is noticed and free flow of dye into duodenum is noted down. Any abnormality in patency, caliber or contour of CBD and flow of dye is noted down. Filling defects in CBD is looked for and noted down. Saline is injected into CBD to wash out dye. After the procedure, ports are placed back, proximal clip is removed and catheter is pulled out. Clips are placed proximal to ductotomy and cystic duct divided completely. Time taken for the procedure is noted down. Any intraoperative or postoperative complications related to IOC is noted down. This follows usual laparoscopic cholecystectomy.
Postoperative period recovery is same as routine laparoscopic cholecystectomy procedure. If stones are detected on IOC, depending on the character of the stones, number of stones and patients overall risk status patient will be subjected to either operative CBD exploration or postoperative ERCP.