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ORIGINAL ARTICLE
Comparison between Laparoscopic Ultrasound and

Intraoperative Cholangiogram in Detection of Common

Bile Duct Stones during Laparoscopic Cholecystectomy for

Cholelithiasis: A Prospective Study

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Mohamed Elkerkary , Gouda Ellabban , Mohamed Shams , Mostafa Abdel-Raheem , Hamdy Shaban , Ahmed Hassan 6
AbstrAct
Introduction: Intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) is valuable in the detection of biliary abnormalities.
In this study, we aimed to investigate the diagnostic accuracy of IOC during LC for the detection of anatomic variations of the biliary system,
as well as the visualization ability of IOC on determining the normal anatomy of the biliary tree.
Materials and methods: This cross-sectional study was conducted on patients who were presented to the surgery outpatient clinic and were
scheduled for elective LC for symptomatic cholelithiasis. Patients underwent intraoperative laparoscopic ultrasound (LUS) before the dissection
of Calot’s triangle and IOC video fluoroscopy examination of the extrahepatic biliary tree.
Results: Our study enrolled 53 patients. No intraoperative complications occurred in all enrolled patients. LUS was successful in all 53 (100%) cases,
while IOC was successful in 50 (94.3%) cases. IOC had accuracy rate of 100% (50 patients) in defining biliary ducts at the porta hepatis compared
to 84.91% (45 patients) for LUS with a failure rate of 15.09% (p = 0.60). Concerning stones detection, LUS accuracy indexes were as follows:
sensitivity = 80%; specificity = 95.83%; positive predictive value (PPV) = 66.67%; negative predictive value (NPV) = 97.87% 99; and diagnostic
odds ratio (DOR) = 92. IOC accuracy indexes were as follows: sensitivity = 80%; specificity = 93.33%; PPV = 57.14%; NPV = 90%; and DOR = 56.
Conclusion: The results of the current study encourage using IOC as an effective, accurate, feasible, and safe technique to visualize the biliary
tree while performing LC.
Keywords: Diagnostic accuracy, Intraoperative cholangiography, Laparoscopic cholecystectomy.
World Journal of Laparoscopic Surgery (2021): 10.5005/jp-journals-10033-1449

IntroductIon 1–3,5,6 Department of Surgery, Faculty of Medicine, Suez Canal
Throughout recent decades, minimally invasive surgery in several University, Ismailia, Egypt
abdominal procedures has been growing. Laparoscopic procedures 4 Department of Surgery, Hywel Dda University Health Board, Wales,
are the most commonly performed procedures in the last few United Kingdom
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years. The surgeon’s failure to palpate abdominal organs is a Corresponding Author: Mohamed Elkerkary, Department of Surgery,
downside of this laparoscopic technique. However, laparoscopic Faculty of Medicine, Suez Canal University, Ismailia, Egypt, e-mail:
cholecystectomy (LC) is an easy and safe procedure as long as m_kerkary@med.suez.edu.eg
there is a clear mapping of the biliary duct. 2,3 Nonetheless, the How to cite this article: Elkerkary M, Ellabban G, Shams M, et al.
description and detailed evaluation of biliary pathways are critical Comparison between Laparoscopic Ultrasound and Intraoperative
for the identification and prevention of the bile duct injury (BDI) Cholangiogram in Detection of Common Bile Duct Stones during
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of the common bile duct stones (CBDS). The invisibility of the Laparoscopic Cholecystectomy for Cholelithiasis: A Prospective Study.
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biliary tract is the main cause of BDI in 97% of diagnosed cases. World J Lap Surg 2021;14(2):69–74.
Moreover, the inadequate skills of surgeons may participate in BDI. Source of support: Nil

To avoid this serious complication that may affect the outcome of Conflict of interest: None
the procedure and the quality of life, different techniques have been
proposed such as intraoperative cholangiography (IOC), passive
infrared cholangiography, dye cholangiography, and laparoscopic
ultrasound (LUS). 4,8,9 specificity of IOC and LUC were comparable. However, LUC was
Regarding IOC, there is a large debate as to whether IOC associated with lower ionizing radiation, lower failure rate, and
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should be used routinely or for select cases. However, it is much quicker performance and can be repeated safely during
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the most commonly used technique to determine the biliary the procedure. The success rate of LUC is estimated to be 100%
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duct. Some limitations were reported for the use of IOC, such compared to 91.3% for IOC. Moreover, some reports demonstrated
as prolongation of the procedure time, cost, and the presence of that the sensitivity of IOC combined with LUS was greater than that
the risk of an inflamed cystic duct and ionizing radiation. 12,13 LUS of IOC and LUS took separately. 8,16–18 Therefore, this study aimed
is a less invasive, cheaper, and faster technique when compared to investigate the diagnostic accuracy of IOC in combination with
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with IOC. A recent meta-analysis showed that the sensitivity and LUC during LC.
© Jaypee Brothers Medical Publishers. 2021 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
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