title: Routine laparoscopic ultrasound can significantly reduce the need for selective intraoperative cholangiography during cholecystectomy.
abstract: BACKGROUND
  The use of intraoperative cholangiography (IOC), routinely rather than selectively, during laparoscopic cholecystectomy (LC) is controversial. Recent findings have shown laparoscopic ultrasound (LUS) to be safe, quick, and effective not only for screening of the bile duct for stones, but also for evaluating the biliary anatomy. This study aimed to evaluate, on the basis of the LC outcome and the cost of LUS and IOC, whether and how much the routine use of LUS would be able to reduce the need for IOC.
  
  
  METHODS
  During LC, LUS was used routinely to screen the bile duct for stones and to evaluate the biliary anatomy, whereas IOC was used selectively only when LUS was unsatisfactory or unsuccessful.
  
  
  RESULTS
  For 193 (96.5%) of 200 patients, LUS was completed successfully, whereas IOC was needed for 7 patients (3.5%). Bile duct stones were identified in 20 patients (10%). For the detection of bile duct stones, LUS yielded 19 true-positive, 175 true-negative, 0 false-positive, and 1 false-negative results. It had a sensitivity of 95%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 99.4%. The postoperative complications included bile leaks from the liver bed in two patients and a retained bile duct stone in one patient. If IOC had been used selectively in a traditional manner on the basis of preoperative risk factors, IOC would have been needed for 77 patients (38.5%). The total cost of LUS plus IOC for the current 200 patients was 26,256 dollars. The total estimated cost of selective IOC, if it had been performed for the 77 patients, would have been 31,416 dollars.
  
  
  CONCLUSIONS
  Routine LUS accurately diagnosed bile duct stones and significantly reduced the need for selective IOC from a potential 38.5% to an actual 3.5% without adversely affecting the outcome of the LC or increasing the overall cost. The routine use of LUS during LC is accurate and cost effective.
authors.affiliation: Department of Surgery, University of Hawaii and Kuakini Medical Center, 347 North Kuakini Street, Honolulu, Hawaii 96817, USA. j.machi@surgedinc.org
authors.forename: J
authors.initials: J
authors.lastname: Machi
authors.forename: A J
authors.initials: AJ
authors.lastname: Oishi
authors.forename: T
authors.initials: T
authors.lastname: Tajiri
authors.forename: K M
authors.initials: KM
authors.lastname: Murayama
authors.forename: N L
authors.initials: NL
authors.lastname: Furumoto
authors.forename: R H
authors.initials: RH
authors.lastname: Oishi
mesh_terms: D000328:Adult; D000368:Aged; D002758:Cholangiography / Q000379:methods / Q000706:statistics & numerical data; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000379:methods*; D005260:Female; D042882:Gallstones / Q000000981:diagnostic imaging* / Q000601:surgery*; D006801:Humans; D007431:Intraoperative Complications / Q000000981:diagnostic imaging / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods; D011237:Predictive Value of Tests; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional / Q000379:methods