Routine versus selective intraoperative cholangiography.

Since its introduction 60 years ago, intraoperative cholangiography (IOC) has reduced the incidence of unnecessary common bile duct (CBD) explorations from 66% to less than 5%. However, the use of routine IOC during cholecystectomy remains controversial. Routine IOC during laparoscopic cholecystectomy reduces the incidence, level, and severity of bile duct injuries. Performing routine IOC with CBD exploration eliminates the need for postoperative endoscopic retrograde cholangiopancreatography or endoscopic sphincterotomy in the 1.4% to 3.5% of postoperative patients with abdominal pain or retained stones, thereby also eliminating the need for reoperation after failed endoscopic sphincterotomy. The financial cost of routine IOC is equal to or less than the cost of treating the severe bile duct injuries that are prevented as well as the cost of the work-up and treatment of patients with retained stones who have not had IOC. A policy of routine IOC sets operative priorities and improves the surgical skills that are necessary for laparoscopic transcystic duct CBD exploration.