title: Optimising laparoscopic cholangiography time using a simple cannulation technique.
abstract: BACKGROUND
  Opponents of the routine use of intraoperative cholangiography (IOC) express concern over its technical difficulty and the length of time it takes.
  
  
  OBJECTIVE
  To evaluate the impact of our cystic duct cannulation (CDC) technique, as implemented by one consultant and his trainees, on the IOC time.
  
  
  METHODS
  IOC is done routinely in all the laparoscopic cholecystectomies (LCs) undertaken in our unit. We carried out a prospective audit over a period of 18 months, recording the IOC time in consecutive patients undergoing laparoscopic cholangiography (LC) with and without laparoscopic common bile duct exploration (LCBDE). The total IOC time was considered to consist of two components: cystic duct cannulation (CDC) time and fluoroscopy time. The IOC time was further analysed according to the difficulty of cannulation and the operator experience. Special consideration was given to the LCBDE cases. We also describe the detailed steps of our CDC technique.
  
  
  RESULTS
  Over a period of 18 months 243 patients underwent LC. IOC was completed in 240 patients (98.8% success rate). Of those, 194 were females (81%). The mean age was 50 years (range 18-85 years). The mean total IOC time was 6 min, with a CDC time of 2 min, and fluoroscopy time of 4 min. On further analysis, CDC was considered easy in 86% of cases with a mean CDC time of 1.5 min and total IOC time of 4.3 min. When cannulation was difficult (14% of cases) a cholangiography clamp had to be used to prevent leakage of contrast. In difficult cases, the CDC and IOC mean times were 5 and 8.5 min, respectively. As would be expected, trainees spent more time performing cannulation and completing the IOC than the specialist surgeon (3.8 versus 1.8 min, and 7.2 versus 5.6 min, respectively). These differences were statistically but not clinically significant. Similarly, the IOC time was also significantly increased in LCBDE (13 min). This was mainly due to an increase in fluoroscopy time (10 min) rather than CDC time (3 min).
  
  
  CONCLUSIONS
  The IOC time could be optimised by using a simple and learnable cannulation technique to less than 5 min in most LCs. Surgeons should not, therefore, refrain from using this important investigation on selective or routine basis, subject to their policy for dealing with patients with suspected bile duct stones.
authors.affiliation: Department of Surgery, Laparoscopic and Upper GI Unit, Monklands Hospital, Airdrie, Lanarkshire, Scotland, UK. A.Nassar@clinmed.gla.ac.uk
authors.forename: Ahmad H M
authors.initials: AH
authors.lastname: Nassar
authors.forename: Gamal
authors.initials: G
authors.lastname: El Shallaly
authors.forename: Ahmed H
authors.initials: AH
authors.lastname: Hamouda
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002758:Cholangiography / Q000379:methods*; D002983:Clinical Competence; D003287:Contrast Media; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D015641:Radiography, Interventional / Q000379:methods*; D015642:Radiology, Interventional / Q000193:education*; D018709:Statistics, Nonparametric
chemical_list: D003287:Contrast Media