ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY AS A PRELUDE TO LAPAROSCOPIC CHOLECYSTECTOMY ProfB KRISHNA RAU*, Lt Col KM HARIKRISHNAN+ ABSTRACT Seventy pntients undergping lnparoscopic cholecystectomy were evaluated with endoscopic retrograde cholangiography maC) preoperatively, All the ERCs were performed by the laparoscopic surgeon. 1 to 30 days prior to surgery. In all cases including those converted to open cholecystectomy (5 out of 70, 7.1 %), ERC helped in clear delineation ofthe biliary tree, cystic duct and gallbladder, making dissection of the Calot's triangle safe. Four cases of common bile duct (CBD) stones detected at ERC were managed by papillotomy and basketing. In nine cases (12.8%). anomalies {Ifthe biliary tree were detected. Average time taken for ERC was 12 minutes (7-28 minutes): while intraopertaive cholangiogram (one case) took 25 minutes. ERC gives n clear outline of the bilinry anatomy and greatly facilitates laparoscopic cholecystectomy, It helps avoid gppn cholecYlifl!(ltQJl1Y because of CBD stones. It also reduces the laparoscopic operating tinle by the duriltion normll1ly taken tp do intraoperative cholangiography. MJAFI 1994; 50 : 271-2'14

KEY WORDS: Cholangiography; Endoscopy; Cholecystectomy; Laparoscopy.

Introduction here is c.onsiderable concern about the occurrence of biliary ductal injury during laparoscopic cholecystectomy [1]. Variou8 studies have reported an incidence of 0.01 to 2.0% biliary tree injuries [2,3]. Delineation of the biliary tree during or prior to gallbladder surgery js essential to minimise the risk of injury to the ductal system [4,5]. Investigations such as ultral'iound examination, computed tomography (CT) Bcan, :scintigraphy, percutaneous transhepatic cholangiography, infusion cholapgioflrapny, ERC and peroperative Qholangipgr~phy can help evaluate the biliary anatomy. The presence of any CBD "tpne~ Clin. be det~ct~d and appropriate management pl@Iled. W~ Clecided to study the usefulness of ER.e Ill:! a preoperative invelltigative tool in om laparoscopic cholecystectomy (LC) patients,

T

Material and Methods

Seventy laparoscopic cholecystectomies were done between Nov 1991 and Sep 1992. all performed by a single team. There was no preselection of patients for LC. There were 14 males and 56 females. with a mean age of 42.5 years (27 to 69 years). ERC was carried out as part of the routine workup in all cases. The procedure was performed by the surgeon doing the laparoscopic cholecystectomy. Siemen's C - Arm screening machine and Olympus EVIS 100 video endoscopic system were used throughout. ERC was done 1 to ~O days before the laparoscopic cholecystectomy (Table t). The majority of patients (59 cases, 8~%) were operated within 48 hours of the ERe. Long interval between ERC and sq.rgery in 3 cases was fpr the convenience of these patients. Biliary tree was cannulated either directly or after papillotomy when necessary. When C~D stones were enIJountered (four patients, 5.7%), they

* Emeritus Professor. Ta~iI Nadu MGRMedicai Uni;~rsity am! MediGal Director Cum Consultant Surgoon and Endoscopist. Willingdon Hospital, Nungambakkam, Madras 600 006. + Classified Specialist (Surgery) and Surgical Gastroenterologist. Command Hospital (Eel. Calcutta 700027.

272 B KRISHNA RAU and KM HARIKRISHNAN TABLE 1 Time lag between ERe and LC Time lag (days)

MJAFJ, 50 : 4, OCTOBER 1994

Results

Cases

PercfHlt

21

30.0%