Selective Cholangiography Current Role in Laparoscopic Cholecystectomy

KEITH D. LILLEMOE, M.D., CHARLES J. YEO, M.D., MARK A. TALAMINI, M.D., BERNADETTE H. WANG, B.S., HENRY A. PITT, M.D., and THOMAS R. GADACZ, M.D.*

The initial 22-month experience with laparoscopic cholecystectomy in 400 patients employing an algorithm of selective cholangiographic evaluation is reported. Preoperative or postoperative endoscopic retrograde cholangiography was performed whenever stones were suspected clinically. Preoperative endoscopic retrograde cholangiography was performed in 44 patients (11%), in whom 14 (3.5%) had an endoscopic sphincterotomy with extraction of common bile duct stones. Intraoperative cholangiography was performed in only eight patients (2%) almost exclusively to acquire experience with the technique, and all cholangiograms were normal. Laparoscopic cholecystectomy was successfully completed in 96% of the patients. There were no deaths in this series, and major complications occurred in only 5% of patients. Two patients (0.5%) had a significant common bile duct injury that was recognized and successfully repaired at the initial operation. No late common bile duct strictures have been recognized. Six patients (1.5%) underwent postoperative endoscopic retrograde cholangiography for suspected common bile duct stones, with three patients requiring endoscopic sphincterotomy and stone extraction. This experience suggests that the use of preoperative and postoperative endoscopic retrograde cholangiography can be based on clinical presentation and laboratory evaluation and does not need to be performed routinely. Routine intraoperative cholangiography is not necessary in most patients undergoing laparoscopic cholecystectomy. The authors conclude that laparoscopic cholecystectomy can be performed safely with the selective use of cholangiography.

T n HE ROLE OF routine intraoperative cholangiography during cholecystectomy has been debated for years. Arguments in favor of routine cholangiography have included: (1) identification of clinically unsuspected common bile duct (CBD) stones, (2) defiPresented at the 103rd Annual Scientific Session of the Southern Surgical Association, Hot Springs, Virginia, December 1-5, 1991. Address reprints requests to Keith D. Lillemoe, M.D., Blalock 656, 600 North Wolfe Street, The Johns Hopkins Hospital, Baltimore, MD 21205. * Current address: Department of Surgery, Medical College of Georgia, Augusta, Georgia. Accepted for publication January 13, 1992.

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From the Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland

nition of the anatomy of the extrahepatic biliary tree to prevent CBD injuries, and (3) development of experience with the technique. Currently the same arguments are being debated concerning routine use of intraoperative cholangiography during laparoscopic cholecystectomy. One factor used to support the use of routine cholangiography is the higher incidence of bile duct injuries reported in the early series of laparoscopic cholecystectomy. 1-5 Advocates of routine cholangiography have stressed that defining the biliary anatomy at laparoscopy before dividing any ductal structure will reduce the rate of significant bile duct injury.8 Routine preoperative endoscopic retrograde cholangiography (ERC) also has been advocated before laparoscopic cholecystectomy. The authors' initial bias was that laparoscopic cholecystectomy can be performed safely in most patients with selective use of preoperative and intraoperative cholangiography. We have applied the algorithm of selective preoperative ERC for patients with suspected CBD stones, using endoscopic sphincterotomy when stones were found. We have used intraoperative cholangiography rarely in our initial experience with laparoscopic cholecystectomy. This report suggests that laparoscopic cholecystectomy can be performed safely with selective use of cholangiography. Clinical Material Four hundred consecutive patients with symptomatic gallbladder disease underwent attempted laparoscopic cholecystectomy at the Johns Hopkins Hospital between December 1989 and October 1991. All patients were evaluated before operation by one of the authors, who established the need for cholecystectomy and completed

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a standard preoperative evaluation. During our initial months of this experience, strict patient selection criteria were applied to optimize the results during the learning phase of this procedure. Currently, however, more than 95% of patients referred to the authors undergo an attempt at laparoscopic cholecystectomy.9 Evaluation for CBD stones consisted of ultrasonography to define the number and size of gallstones and to determine CBD size. Preoperative serum amylase and liver function tests (serum bilirubin, alkaline phosphatase, alanine aminotransferase, and aspartate aminotransferase) were performed routinely. Patients were referred for preoperative ERC at the discretion of the primary surgeon on the basis of these preoperative studies. Laparoscopic cholecystectomy was performed by standard techniques.1"2'5"10 At least one of the authors served as the surgeon or first assistant during all of the cases. A 300 forward oblique viewing telescope was used in all cases to optimize visualization. Cephalad traction on the fundus and lateral traction on the infundibulum of the gallbladder were essential to expose and safely dissect the triangle of Calot. The dissection of the cystic duct was performed at its junction with the gallbladder infundibulum. An adequate length of the cystic duct was exposed before clipping and dividing the structure. No attempt was made to dissect the cystic duct down to its junction with the CBD. The cystic artery was then identified, doubly clipped, and divided. The electrocautery was used to dissect the gallbladder from the liver bed. Data were prospectively collected from all patients. Follow-up was obtained on all patients either by an outpatient visit with the primary surgeon or by contact with the referring physician within 1 month of operation.

Results Patient Population

Of the 400 patients, 293 were women (73%) and 107 were men (27%). The mean age was 47.9 years (range, 15 to 96 years). Previous abdominal operations had been performed in 28% of patients. Most procedures were lower abdominal (22%) and were primarily obstetric or gynecologic in nature. An upper abdominal incision was present in 2.8% of patients. Operations involving the umbilicus, primarily umbilical herniorrhaphy, had been performed in 2.5% of patients. Obesity, defined as at least 40 pounds above ideal body weight, was present in 25% of patients.

Symptoms The primary indications for laparoscopic cholecystectomy are shown in Table 1. Chronic biliary tract symptoms were present in 88% of patients. In 10 patients

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TABLE 1. Indications for Laparoscopic Cholecystectomy in 400 Patients

Presentation

N

Chronic biliary tract symptoms Calculus Acalculus Acute cholecystitis Previous episode Current admission Gallstone pancreatitis Previous episode Current admission

352 (88%) 342 (85.5%) 10 (2.5%) 30 (7.5%) 20 (5.0%) 10 (2.5%) 22 (5.5%) 14 (3.5%) 8 (2%) 19 (4.8%) 9 (2.3%) 10 (2.5%) 9 (2.3%)

Cholangitis/jaundice Previous episode Current admission Gallbladder polyps

(2.5%), chronic typical biliary symptoms were present without demonstrable gallstones. Cholecystectomy was offered to these patients after extensive workup to eliminate other causes for the symptoms. Although chronic biliary tract symptoms were present in 88% of patients, surgical referral in 18% of patients was based on a complication of cholelithiasis. Thirty patients (7.5%) presented with acute cholecystitis. In 10 of these patients (2.5%), laparoscopic cholecystectomy was attempted during the acute attack. In the remaining 20 patients (5%) laparoscopic cholecystectomy was attempted 6 to 8 weeks after the acute episode. Twenty-two patients (5.5%) presented with gallstone pancreatitis. Laparoscopic cholecystectomy was performed in eight ofthese patients during the initial hospitalization, whereas 14 patients had interval laparoscopic cholecystectomy performed after the index admission for gallstone pancreatitis. Symptoms of choledocholithiasis, jaundice, or cholangitis were present at the time of referral in 19 ofthe patients (4.8%). Ten of these patients underwent laparoscopic cholecystectomy during the initial admission after successful endoscopic management of their bile duct calculi. Preoperative and Intraoperative Cholangiography Preoperative ERC was performed in 44 patients (I1%). Thirty-one patients (7.8%) underwent preoperative cholangiography because of a high clinical suspicion of choledocholithiasis. Symptomatic choledocholithiasis, with gallstone pancreatitis, cholangitis, or jaundice, occurred in 24 patients, whereas seven patients underwent ERC for symptomatic gallstones with abnormal liver function tests. Fourteen ofthese 31 patients (45%) had CBD stones identified by preoperative ERC. An endoscopic sphincterotomy and stone extraction was performed in all 14 patients. The overall incidence of documented preoperative choledocholithiasis requiring endoscopic sphincterotomy was 3.5%. Before surgical referral, 13 patients underwent ERC for evaluation of biliary tract symptoms

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without clinical or laboratory evidence of choledocholithiasis. No CBD stones were identified in these patients. In nine patients, the indication for ERC was for the evaluation of typical biliary tract symptoms without documented gallstones. Four patients with known gallbladder stones underwent ERC by the referring physician in the evaluation of abdominal pain without specific indications of choledocholithiasis. Transcystic duct cholangiography during laparoscopic cholecystectomy was performed in eight patients (2%). In six patients, intraoperative cholangiography was performed to gain experience with the technique, without other specific indications. In two patients, abnormal liver function tests were the indication for cholangiography. All cholangiograms were successfully completed without complication. No CBD stones were identified, nor did the cholangiographic findings influence the performance of the laparoscopic cholecystectomy. Laparoscopic Cholecystectomy: Intraoperative Results and

Complications Laparoscopic cholecystectomy was successfully completed in 383 of the 400 patients (95.8%). The reasons for conversion to open cholecystectomy are shown in Table 2. Significant inflammation precluding laparoscopic cholecystectomy was encountered in nine patients. Three patients required conversion to open cholecystectomy because of inflammation during an attack of acute cholecystitis. The single patient requiring conversion due to bleeding was also a patient with acute cholecystitis that occurred after a lower extremity vascular reconstruction. This patient had been systemically heparinized, and although preoperative coagulation studies were corrected, bleeding from the liver bed required laparotomy. The patient, who was anemic before surgery, received 2 units of packed red blood cells. The overall success rate in patients undergoing laparoscopic cholecystectomy for acute cholecystitis was 60% (6/10). None of the 20 patients with a history of recent acute cholecystitis required conversion to open cholecystectomy. Thus, the overall success of laparoscopic cholecystectomy with a history of acute cholecystitis was 87%. Six patients requiring conversion did TABLE 2. Reasons for Conversion to Open Cholecystectomy in 17 Patients Reason

Inflammation Common bile duct injury Abnormal anatomy

Bleeding Injury to accessory hepatic duct Trochar injury to small bowel Obesity

N 9 (2.3%) 2 (0.5%) 2 (0.5%) 1 (0.3%) 1 (0.3%) 1 (0.3%) 1 (0.3%)

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not have clinically apparent acute cholecystitis. A previous endoscopic sphincterotomy had been performed for bile duct stones in two of these six patients, however. Abnormal anatomy in two patients, including an intrahepatic gallbladder and a double cystic duct, required conversion to open cholecystectomy. A morbidly obese patient, weighing more than 320 pounds, required conversion to an open cholecystectomy because of inability to adequately retract and expose the gallbladder infundibulum and cystic duct. Intraoperative complications led to conversion to an open procedure in the remaining four patients. Major bile duct injury occurred in two patients. Both injuries occurred between cholecystectomy numbers 100 and 200 in our series. One patient had significant chronic inflammation with scarring of the triangle of Calot. During initial dissection in this area and before the cystic duct could be identified, leakage of bile was visualized, and the patient was converted to an open procedure. At laparotomy, it was determined that the patient had a low hepatic duct bifurcation with a short cystic duct inserting into the right hepatic duct. The right hepatic duct was injured at the hepatic bifurcation. Immediate reconstruction was performed with a Roux-en-Y bilateral hepaticojejunostomy constructed over transhepatic stents. The patient had no postoperative complications. At 14 months after reconstruction, her biliary stents have been removed, and the patient is asymptomatic with normal liver function tests. The other major bile duct injury was a transection of the CBD. Although no significant inflammation or difficulty during dissection was encountered, a structure suspected of being the cystic duct was doubly clipped and divided. Further dissection showed the divided structure to be the CBD. After recognition of the injury, the patient was opened, and the bile duct was reconstructed with a Roux-en-Y hepaticojejunostomy over a T-tube in the common hepatic duct. The patient is now 12 months after the reconstruction and is asymptomatic. The T-tube has recently been removed with no evidence of a postoperative stricture. In the remaining patients, there have been no late postoperative bile duct injuries recognized, and no bile duct strictures have occurred in subsequent follow-up. A partial-thickness incision in a segmental hepatic duct occurred during cutting of the cystic duct in one patient. Concern about the nature of the injury necessitated conversion to open cholecystectomy. A cystic duct cholangiogram identified an intact hepatic duct bifurcation and was otherwise normal. The injured duct was less than 2 mm in size, and it was ligated. The patient recovered without sequelae. The final intraoperative complication was an injury to a loop of small bowel during trochar placement. The patient had a history of two previous lower abdominal operations, including a hysterectomy and an

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appendectomy for ruptured appendicitis. Significant adhesions to the anterior abdominal wall may have precluded successful laparoscopic cholecystectomy; however, the use of the Hassan cannula may have prevented the enterotomy. The patient underwent small bowel repair and open cholecystectomy and had an uncomplicated recovery.

TABLE 4. Length ofStay After Successful Laparoscopic Cholecystectomy in 383 Patients

Length of Stay

N

Outpatient 1 day 2 days >2 days

1 (0.3%) 304 (79%) 51 (13%) 27 (7%)

Postoperative Complications

There were no deaths in the series. All complications of laparoscopic cholecystectomy are shown in Table 3. The overall complication rate in this series is 9.3%. Major complications requiring either conversion to open cholecystectomy, reoperation, major postoperative intervention, or significant prolongation of hospital stay occurred in 20 patients (5%). Minor complications occurred in 17 patients (4.3%). The most frequent complication was urinary retention, which delayed hospital discharge in 10 patients. Six patients (1.5%) were readmitted after discharge with symptoms ofabdominal pain and abnormal liver function tests, suggesting a retained CBD stone. Endoscopic retrograde cholangiography was performed on all six patients, with retained CBD stones identified and extracted in three patients. In the other three patients, no stone was identified, the symptoms resolved, and the liver function abnormalities normalized. Two of these six patients with retained CBD stones had a preoperative ERC performed. One patient had a preoperative CBD stone removed after an endoscopic sphincterotomy. The patient underwent successful laparoscopic cholecystectomy, but returned 5 days after operation with abdominal pain and jaundice. Repeat ERC showed a CBD stone, which was extracted without a second sphincterotomy. The final patient had a negative preoperative cholangiogram. The only complication of ERC performed either before or after operTABLE 3. Complications of Laparoscopic Cholecystectomy

Complication

Intraoperative Major bile duct injury Enterotomy due to trochar injury Accessory bile duct ligation Bleeding (requiring blood transfusion) Dental injury during intubation Postoperative Urinary retention Retained common bile duct stone Cystic duct leak

Omphalitis Umbilical wound infection Peritonitis Bleeding Pulmonary embolus Umbilical hernia

N

2 (0.5%) 1 (0.3%) 1 (0.3%) 1 (0.3%) 1 (0.3%) 10 (2.5%) 6 (1.5%) 5 (1.3%) 3 (0.8%) 2 (0.5%) 2 (0.5%) 1 (0.5%) 1 (0.5%) 1 (0.3%)

ation was a single episode of pancreatitis after a sphincterotomy and stone extraction. A postoperative cystic duct leak occurred in five (1.3%) of the 383 patients completing laparoscopic cholecystectomy. Three of the five leaks were recognized within 36 hours of laparoscopic cholecystectomy. Hepatobiliary radionucleotide scanning confirmed the leak at the cystic duct in all three patients, and immediate laparotomy and ligation of the cystic duct stump was performed. The patients recovered without complications. One patient was readmitted 5 days after discharge with bilious ascites. Endoscopic retrograde cholangiography demonstrated a cystic duct leak. An endoscopic stent was placed; however, the bile leak persisted, and laparotomy and ligation of the cystic duct stump was performed. The final patient developed a subhepatic collection, associated with a fever, which was percutaneously drained. After 48 hours, the drainage became bilious. A sinogram through the drainage catheter demonstrated a cystic duct leak. A percutaneous transhepatic biliary catheter was placed, and the leak closed spontaneously. The patient recovered without further complication, although the postoperative stay was 30 days in duration. Two patients developed postoperative abdominal pain, tenderness, and fever. No evidence of a bile leak could be demonstrated, and the patients recovered with a course of intravenous antibiotics. After hospital discharge, five patients have developed wound complications. Three developed periumbilical cellulitis that responded to antibiotics. Two patients developed a deep periumbilical wound infection that required the incision to be opened and local wound care. One patient returned several months after laparoscopic cholecystectomy with a periumbilical incisional hernia. The final technical complication was a young man with chronic renal failure on hemodialysis, who underwent an uneventful laparoscopic cholecystectomy. The hematocrit on postoperative day 1 decreased from 21 % to 15%. Computed tomography suggested a subhepatic hematoma. The patient received 2 units of packed red blood cells and recovered without further problems. The length of hospital stay for laparoscopic cholecystectomy is shown in Table 4. Most of patients were discharged on the first postoperative day, often less than 24 hours after surgery. The range of hospitalization was 0 to

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30 days. The mean length of hospital stay in the 17 patients requiring conversion to open cholecystectomy, including those sustaining bile duct injury, was 6.7 days. Seven patients were readmitted after initial discharge for complications as discussed above. Discussion Laparoscopic cholecystectomy is now the treatment of choice for most patients with symptomatic gallbladder disease. The overall results and complications from several series numbering into the thousands are now available.'1-8"''1'3 From these initial reports, the incidence of major bile duct injury may be as high as two to five times that of open cholecystectomy. The actual rate of bile duct injury may be even higher, in that most early reports have been from centers with a large experience with the procedure. This increased rate of bile duct injury may simply reflect the learning curve associated with a new technique. It is possible, however, that the technique of laparoscopic cholecystectomy, with early division of the cystic duct, may be inherently more dangerous than traditional cholecystectomy. This final possibility has led a number of authors to stress the necessity of routine operative cholangiography to prevent bile duct injuries. 6-8 Those who favor routine use of intraoperative cholangiography report numerous anatomic anomalies found by cholangiography where recognition has avoided potential complications.6-8 However, the significance of such findings is unclear, as is the proof that their recognition truly prevents injury. Bile duct injuries have been reported despite the performance of intraoperative cholangiography.6-8"2 Furthermore, bile duct injuries may result from the instrumentation necessary to perform operative cholangiography. The most serious bile duct injury, that of complete transection of the CBD, is affected little by the current technique of intraoperative laparoscopic cholangiography. With most techniques, the proximal aspect of the duct, which is to be cannulated, is clipped before creating a small incision in the duct to insert the cholangiocatheter. If, indeed, the duct that is clipped or incised is the CBD, an injury has already been created, and some form of repair or reconstruction will be necessary. The recognition of a short cystic duct is one abnormality frequently cited as an important variant that can be recognized by operative cholangiography. It is our belief that the key point in avoiding injury in such cases is beginning the dissection at the junction of the gallbladder infundibulum with the cystic duct. All ductal structures to be clipped and divided must have this relationship clearly defined. The use of the 300 telescope may improve visualization of the critical anatomy of the cystic duct-CBD

junction. The incidence of major bile duct injury in this series was 0.5%. These results are consistent with the incidence

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of bile duct injury in most other series either using routine or selective operative cholangiography. One ofthe injuries in this series occurred before cholangiography could have been performed. With the other injury, it is unlikely that operative cholangiography would have altered the management, because the proximal aspect of the bile duct would have already been clipped to perform the study. Both injuries in this series were recognized intraoperatively, and immediate biliary reconstruction was performed. Intraoperative recognition of a bile duct injury avoids the potential for postoperative biliary fistulas or sepsis. In addition, repair of the biliary tree can be done in an operative field without significant inflammation or adhesions. Advocates of routine intraoperative cholangiography cite the detection ofbile duct stones as the final indication for its use. This issue has been addressed extensively in reports from the prelaparoscopic cholecystectomy era, and these data remain valid now. The results from studies addressing the role of routine intraoperative cholangiography in the open cholecystectomy era report an incidence of unsuspected CBD stones ranging from 1.2% to 12.4%,4"-8 Large series of cholecystectomies without cholangiography report an incidence of residual stones as low as 0.3%. 19-2 1 Furthermore, the incidence of false-positive cholangiograms of 2% to 16% 17,22-24 may lead to unnecessary conversion to open cholecystectomy or postoperative investigations to search for stones. The management of CBD stones during laparoscopic cholecystectomy presents a significantly different problem than traditional cholecystectomy. In the open procedure, if bile duct stones are recognized cholangiographically, a CBD exploration or transduodenal procedure can be performed at the same time, with only a minimal increase in morbidity rate. Although scattered reports of transcystic duct exploration or even formal common duct exploration have recently appeared,2527 the potential for serious bile duct injuries with such procedures is high, especially with a nondilated biliary system.28 The problem of choledocholithiasis, as well as concern for bile duct injury, has led for a call for routine preoperative ERC in some centers. It has been our practice, however, to selectively evaluate the biliary tree with preoperative ERC. Patients were selected for preoperative cholangiography on the basis of clinical presentation and preoperative liver function tests. The patients in this series represent a wide spectrum of biliary tract disease, including complications of CBD stones, such as gallstone pancreatitis (5.5%) and cholangitis or jaundice (4.8%). Overall, only 44 patients in this series ( 1%) underwent preoperative ERC. Yet, if only those studies obtained by the primary surgeon for preoperative evaluation for possible CBD stones are considered, then the preoperative cholangiography rate was only 7.8%, with 45% of these pro-

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cedures finding choledocholithiasis. Using only selecti-ve preoperative cholangiography and rarely using intraoperative cholangiography (after an initial learning experience), we report only a 1.5% incidence of suspected retained CBD stones (with only 0.75% actually documented by a positive postoperative cholangiogram). These results compare favorably with studies of both laparoscopic and open cholecystectomy using routine cholangiography. In summary, laparoscopic cholecystectomy can be performed safely without routine use of cholangiography. The incidence of bile duct injury in this series compares favorably with other reports in the literature. These results serve to support the role of careful dissection and visualization of ductal structures before division and suggest that intraoperative cholangiography is not necessary. The selective use of preoperative and postoperative cholangiography, based on clinical presentation, can successfully manage choledocholithiasis without significant complications, while still allowing completion of laparoscopic cholecystectomy in up to 95% of patients. We conclude that laparoscopic cholecystectomy can be performed safely with selective use of cholangiography. Acknowledgments The authors thank Joanne Coleman, R.N., and Patricia Kal Sauter, R.N., for their assistance in collection of the patient data, and Anne Serna for the preparation of this manuscript.

References 1. Peters JH, Ellison EC, Innes JT, et al. Safety and efficacy of laparoscopic cholecystectomy: a prospective analysis of 100 initial patients. Ann Surg 1991; 213:3-12. 2. Zucker CA, Bailey RW, Gadacz TR, Imbembo AL. Laparoscopic guided cholecystectomy. Am J Surg 1991; 161:36-44. 3. The Southern Surgical Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991; 324:1073-1078. 4. McKernan JB. Laparoscopic cholecystectomy. Am Surg 1991; 57: 309-312. 5. Schirmer BD, Edge ST, Dix J, et al. Laparoscopic cholecystectomy: treatment of choice for symptomatic cholelithiasis. Ann Surg 1991; 213:665-677. 6. Berci G, Sackier JM, Paz-Partlow M. Routine or selected intraoperative cholangiography during laparoscopic cholecystectomy. Am J Surg 1991; 161:355-360.

DISCUSSION

DR. C. RANDLE VOYLES (Jackson, Mississippi): I wholeheartedly agree with the conclusion that operative cholangiography should not be done on a routine basis to (1) prevent bile duct injury or (2) identify common duct stones. In a personal series of over 600 laparoscopic cholecystectomies, I have had no duct injury or retained stone in patients selected not to have operative cholangiography. However, we must emphasize that endoscopic sphincterotomy has a well-documented morbidity rate of about 8%. We have seen pancreatitis and death in a 25-year-old woman who had an endoscopic cholangiogram out of state. Accordingly, we have tried to identify small stone disease that can be managed with intraoperative flouroscopic basket manipulation; we have succeeded in about 60% to 70% of cases. This technique is easy to do with instruments that you probably already have. Furthermore, flouroscopic cholangiograms obviate the need for the more expensive plastic cannulas.

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7. Hunter JG. Avoidance of bile duct injury during laparoscopic cholecystectomy. Am J Surg 1991; 162:71-76. 8. Sackier JM, Berci G, Phillips E, et al. The role of cholangiography in laparoscopic cholecystectomy. Arch Surg 1991; 126:10211026. 9. Lillemoe KD, Magnuson TH, Gadacz TR, et al. How many Americans will be candidates for laparoscopic cholecystectomy? Gastroenterology 1991; 100:A324. 10. Gadacz TR, Talamini MA, Lillemoe KD, Yeo CJ. Laparoscopic cholecystectomy. Surg Clin North Am 1991; 70:1249-1262. 11. Cushieri A, Dubois F, Mouiel J, et al. The European experience with laparoscopic cholecystectomy. Am J Surg 1991; 161:385387. 12. Graves HA, Ballinger JF, Anderson WJ. Appraisal of laparoscopic cholecystectomy. Ann Surg 1991; 213:655-664. 13. Spaw AT, Reddick EJ, Olsen DO. Laparoscopic laser cholecystectomy: analysis of 500 procedures. Surg Lap Endosc 1991; 1:2-7. 14. Jolly PC, Baker JW, Schmidt HM, et al. Operative cholangiography: a case for its routine use. Ann Surg 1968; 104:484-488. 15. Schulenberg CAR. Operative cholangiography: 1000 cases. Surgery 1969; 65:723-739. 16. Pagana TJ, Stahlgren LH. Indications and accuracy of operative cholangiography. Ann Surg 1980; 115:1214-1215. 17. Mills JL, Beck DE, Harford FJ Jr. Routine operative cholangiography. Surg Gynecol Obstet 1985; 161:343-345. 18. Kitahama A, Kerstein MD, Overby JL, et al. Routine intraoperative cholangiogram. Surg Gynecol Obstet 1986, 162:317-322. 19. Barlett MK, Quinby WC. Mortality and complications of cholecystectomies and choledochostomy for chronic cholecystitis. N Engl J Med 1956; 254:154-156. 20. Gerber A, Apt MK. The case against routine operative cholangiography. Am J Surg 1982; 143:734-736. 21. Bogokowsky H, Slutzki S, Zaidenstein L, et al. Selective operative cholangiography. Surg Gynecol Obstet 1987; 164:124-126. 22. Skillings JC, Williams JS, Hinshaw JR. Cost-effectiveness of operative cholangiography. Am J Surg 1979; 137:26-31. 23. Doyle PJ, Ward-McQuaid JN, McEwe SA. The value of routine perioperative cholangiography: a report of 4000 cholecystectomies. Br J Surg 1982; 69:617-619. 24. Levine SB, Lerner HJ, Leifer ED, Lindheim SR. Intraoperative cholangiography: a review of indications and analysis of age-sex groups. Ann Surg 1983; 198:692-697. 25. Bagnato VJ, McGee GE, Hatter LE, et al. Justification for routine cholangiography during laparoscopic cholecystectomy. Surg Lap Endosc 1991; 1:89-93. 26. Quattlebaum JK Jr, Flanders HD. Laparoscopic treatment of common bile duct stones. Surg Lap Endosc 1991; 1:26-32. 27. Petelin JB. Laparoscopic approach to common duct pathology. Surg Lap Endosc 1991; 1:33-41. 28. Ratych RE, Sitzmann JV, Lillemoe KD, et al. Transduodenal exploration of the common bile duct in patients with nondilated ducts. Surg Gynecol Obstet 1991; 173:49-53.

We do obtain cholangiograms in 3% to 4% of patients with difficult anatomy but generally rely on careful dissection more than x-rays to keep us out of trouble. As a helpful pearl, if you are having difficulty sorting out the anatomy, use one of the cholangiogram catheters with a balloon to secure the catheter (do not use clips on what could be the common duct) until the anatomy is more clear. I have three questions: (1) What do you do if you want a preoperative cholangiogram but your endoscopic colleague is unsuccessful? Do you place a percutaneous wire through the liver into the duct? Do you do an open procedure, or do you proceed with intraoperative cholangiograms? (2) We must always question costs. A normal cholangiogram must add $300 to $500 to the patient's bill. Do you know your hospital's charge for laparoscopic cholecystectomy? In a review of 50 patients, the patient charge from my hospital was less than $1900 with an overnight stay. I think that this is the lowest in the nation. (3) How do you manage acute gallbladders with minor enzyme ele-