Is laparoscopic intraoperative cholangiogram a matter of routine?

BACKGROUND Intraoperative cholangiography during laparoscopic cholecystectomy reveals the anatomy of the biliary tree and any stones contained within it. The use of intraoperative cholangiography may be routine for all laparoscopic cholecystectomy. An alternative approach is a selective policy, performing intraoperative cholangiography only for those cases in which choledocholithiasis is suspected on clinical grounds, or those for which the anatomy appears unclear at operation. The literature pertaining to both approaches is reviewed, to delineate their respective merits. METHODS Relevant articles in English were identified from the Medline database, and reviewed. RESULTS The literature reviewed consisted of retrospective analyses. Overall the incidence of unsuspected retained stones was 4%, but only 15% of these would go on to cause clinical problems. The incidence of complete transection of the common bile duct was rare for both routine and selective intraoperative cholangiography policies, and did not differ between them. Rates of minor bile duct injury did not differ between groups, but was more likely to be recognized in the routine group than the selective (P = 0.01). CONCLUSIONS Routine intraoperative cholangiography yields very little useful clinical information over and above that which is obtained with selective policies. Large numbers of unnecessary intraoperative cholangiography are performed under routine intraoperative cholangiography policy, and therefore a selective policy is advocated.