Page 19 - World Journal of Laparoscopic Surgery

Intraoperative Cholangiography Using a Biliary-nose Tube
At the beginning of surgical procedures, surgeons had to In patients without altered locoregional anatomical conditions,
declare their perception of the degree of safety owned, expressing dissection time was between 10 minutes and 35 minutes and
it through a numerical score from 1 to 5 and giving the value of 5 between 20 minutes and 45 minutes when difficult anatomy had
to a mood of peaceful safety. Surgeons knew in which of risk or been found. IOC avoided a lesion of the biliary duct in 7 patients
no-risk group the patient belonged. (10.4%) of which 2 (6.6%) with normal anatomical conditions.
Once the trocars were positioned and the surgeons evaluated Only 1 patient (0.7% of all) had a small stone in CBD. The surgeon
the surgical field, they had to do a survey attributing the following eliminated it during the procedure, washing it through the catheter.
values: All surgeons evaluated their approach to surgery with a score
of 5 before the surgical procedure, also in patients where difficult
• 5 if he was sure of being able to complete the procedure anatomical conditions were expected by the form applied. The
laparoscopically; rating given by the surgeons after the inspection of the operating
• 4 if he was sure to complete the laparoscopic procedure with field was 3 in 21 cases (13 by the junior surgeon).
longer time; Maybe, the IOC previously performed in group A patients
• 3 if he thought he needed to perform an IOC; provided a first picture of the biliary duct map and this had
• 2 if there was the possibility to convert the procedure to open influenced the rapidity in the dissection that was shorted than
surgery; group B without significant difference between senior and junior
• 1 if he wanted to convert immediately.
surgeons. It seems that a preventive view of the biliary ducts can
At the end of the procedures, surgeons had to express their contribute to a faster dissection but it is the IOC performed before
opinion on the usefulness of cholangiography, with also the the section that had a real meaning in avoiding biliary injuries. In
subjective influence that it has had on the procedure. fact, in nine cases surgeons avoid biliary damages thanks to IOC.
In both groups, there were no significative differences in the The form used to hypothesize the anatomical conditions, based
positioning time of the radiological equipment that was about on the elements we have taken into, has shown poor specificity
5 minutes and cholangiography time that was between 3 minutes (67%) and sensitivity (76%).
and 6 minutes.
discussion
results Laparoscopic cholecystectomy is the gold standard for gallbladder
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In group A, “difficult” anatomical conditions were found in 9 of the cholelithiasis but is linked to an increased rate of biliary injuries.
23 patients (39.1%) of no-risk group and in 27 (60%) among the 45 The incorrect visualization of the cystic duct, the CBD, and
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of the risk group (Table 3). When locoregional anatomy was not the cystic artery is often responsible for surgical injuries. The
significantly changed, the dissection time after cholangiography European Association for Endoscopic Surgery’s guideline shows the
was between 10 minutes and 20 minutes. In those patients with importance of dissection and the relevance of the critical view of
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locoregional alterations, the dissection time was between 10 safety (CVS). CVS is not only a dissection method but also the final
minutes and 35 minutes. Transcatheter cholangiography allowed picture that is obtained through a careful and prudent dissection of
the safe recognition of anatomical structures in all patients without the Calot’s triangle to highlight the duct and the cystic artery. 36,37
complications. Surgeons avoided injuries in the patients in which Despite its adoption, however, the percentage of biliary injuries
difficult conditions were not expected thanks to IOC. The second has not decreased even in centers where it is routinely adopted.
cholangiography avoided a lesion of the biliary duct in two patients Laparoscopic surgeons lack three-dimensional (3D) view and
5
of this group. tactile sensitivity causing iatrogenic bile duct injuries. These
In group B, we performed cholangiography after the isolation problems are on the focus of scientific discussion. 3D laparoscopy
of the anatomical structures at Calot’s triangle. In the 42 patients helps surgeons, especially in difficult surgical procedures, but this
of the risk group, we found 31 (73.8%) difficult surgical dissections technology is still not present in most of the surgical departments. 38
and 9 among the 25 in which anatomical alterations were not Since 1932, IOC can help to avoid biliary injuries but its routine
hypothesized (26%) (Table 3). use is controversial: it is very useful to find anatomical biliary
alterations or to find residual/unknown stones in the CBD; 39,40
however, it is expensive in terms of time and costs and it can also
Table 3: Results. There were no significant differences in IOC time. The cause biliary damages by itself. 41,42
form applied showed low sensitivity and specificity The ERCP changed the choledocholithiasis therapy and it let
Results Group A Group B to avoid complications linked to the surgical exploration of CBD.
Patients without surgical com- 68 67 Lots of patients need ERCP because it immediately solves their
plications choledocholithiasis pathology with a short time of hospitalization.
Risk group results 27 of 45 (39.7%) 31 of 42 (46.3%) Nowadays, ERCP is routinely performed and lots of centers follow
No-risk group results 14 of 23 (20.6%) 16 of 25 (23.9%) the sequential treatment in gallbladder/choledocholithiasis. Leaving
Surgical dissection time 24′17″ 32′38″ a biliary-nose tube during ERCP is a simple and safe procedure. It
(minutes) can be useful in sequential therapy in patients who should undergo
No-biliary duct integrity before 2 (2.9%) 7 (10.4%) cholecystectomy. In this way, we can avoid the problems linked to
loss of time and biliary injury due to tube insertion procedure. It can
cutting also be avoided that a stone could pass throw the cystic duct to the
IOC time (minutes) 5 ± 1 4 ± 1 CBD during intraoperative anterograde cholangiography.
Residual stones in CBD 0 1 Surgeons feel more comfortable knowing to have a biliary-
Bile duct injuries 0 0 nose catheter to perform an IOC and this is well expressed in our

World Journal of Laparoscopic Surgery, Volume 14 Issue 1 (January–April 2021) 17