title: The utility of intracorporeal ultrasonography for screening of the bile duct during laparoscopic cholecystectomy.
abstract: Different strategies and imaging modalities have been used to detect common bile duct (CBD) stones during laparoscopic cholecystectomy. We prospectively compared fluoroscopic intraoperative cholangiography (FIOC) and laparoscopic intracorporcal ultrasonography (LICU) in patients undergoing laparoscopic cholecystcctomy for this purpose. In a consecutive series of 607 laparoscopic cholecystectomics, FIOC was used in the first 407 patients, whereas LICU was preferentially applied to the subsequent 200 patients. When LICU documented CBD stones, the duct was flushed with saline solution after intravenous administration of glucagon, and stone persistence or absence was confirmed by FIOC and/or repeat LICU. In the FIOC group, 10 patients were converted to open cholecystectomy and 16 patients did not undergo FIOC. Among the remaining 381 patients, FIOC was successful in 370 (97%). In the LICU group, two patients were converted and LICU was not performed in 26 patients. In the remaining 172 patients, the cystic duct (CBD) junction and the CBD were visualized in all cases (P <0.05 vs. FIOC). The mean (+/- SEM) times required to complete FIOC and LICU were 15. 1 +/- 0.4 minutes and 5.3 +/- 0.2 minutes, respectively (P <0.0001). Choledocholithiasis was detected in 25 patients (7%) undergoing FIOC and in 22 patients (13%) undergoing LICU (P <0.05). In the LICU group, the mean sizes of the stones cleared by ampullary dilatation and flushing (17 of 22, 77%) and those requiring more invasive methods (5 of 22, 23%) were 1.6 +/- 0.2 mm and 2.7 +/- 0.3 mm, respectively (P <0.01). Sludge seen in the CBD by LICU in 10 patients (6%), which disappeared with flushing in all cases. LICU is accurate, safe, and permits more rapid evaluation of bile duct stones than FIOC during laparoscopic cholecystectomy. LICU may be overly sensitive in detecting small stones and sludge, which are of questionable significance. Stones 2 mm or less can usually be cleared by flushing, whereas larger ones often require invasive techniques for removal.
authors.affiliation: Department of Surgery, Washington University School of Medicine, and the Washington University Institute of Minimally Invasive Surgery, St. Louis, MO, USA.
authors.forename: J S
authors.initials: JS
authors.lastname: Wu
authors.forename: D L
authors.initials: DL
authors.lastname: Dunnegan
authors.forename: N J
authors.initials: NJ
authors.lastname: Soper
mesh_terms: D001646:Bile / Q000000981:diagnostic imaging; D002758:Cholangiography; D002763:Cholecystectomy; D017081:Cholecystectomy, Laparoscopic; D003135:Common Bile Duct / Q000000981:diagnostic imaging; D003549:Cystic Duct / Q000000981:diagnostic imaging; D004106:Dilatation; D005260:Female; D005471:Fluoroscopy; D042882:Gallstones / Q000000981:diagnostic imaging* / Q000601:surgery / Q000628:therapy; D005765:Gastrointestinal Agents / Q000008:administration & dosage / Q000627:therapeutic use; D005934:Glucagon / Q000008:administration & dosage / Q000627:therapeutic use; D006801:Humans; D007275:Injections, Intravenous; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D015641:Radiography, Interventional; D012965:Sodium Chloride / Q000008:administration & dosage / Q000627:therapeutic use; D007507:Therapeutic Irrigation; D018084:Ultrasonography, Interventional
chemical_list: D005765:Gastrointestinal Agents; D012965:Sodium Chloride; D005934:Glucagon