Laparoscopic cholecystectomy (LC) is one of the most common surgical procedures. Bile duct injury (BDI) is the most severe complication, with an approximate rate of 0.4% to 1.5% [1,2]. Intraoperative cholangiography (IOC) allows the early identification of BDI and common bile duct (CBD) stones, which is essential to improve medical care. Several surgical associations, such as the French or Swedish ones, recommend systematic IOC performance to reduce the risk of BDI [3,4]. A recent meta-analysis confirmed the usefulness of this procedure [5].

Nevertheless, the consensus is not unanimous, the debate is always open, and the number of proponents who agree with selective cholangiography has grown and continues to grow [6,7].

Five surgical societies (Society of American Gastrointestinal and Endoscopic Surgeons, Americas Hepato-Pancreato-Biliary Association, International Hepato-Pancreato Biliary Association, Society for Surgery of the Alimentary Tract, and The European Association of Endoscopic Surgery) stated that the benefit of IOC in elective non-acute cholecystectomy was inconclusive. Therefore, no recommendation can be made for this procedure could. Nevertheless, IOC has been recommended in situations such as previous acute cholecystitis, uncertainty of biliary anatomy, or BDI [8,9].

Likewise, the Italian recommendations, although acknowledging the importance of IOC in recognizing and treating BDI in selected cases, only recommends its systematic use due to a need for sufficient scientific evidence [10].

Furthermore, the European Association for the Study of Liver does not recommend routine or selective execution of IOC in patients at low risk of CBD stones [11].

This study aimed to retrospectively evaluate the impact of IOC on patients undergoing elective LC at our hospital center.

In this study, we demonstrated that the failure rate of IOC was 14.7%, it was incomplete or unclear in more than 10% of cases, it had a sensitivity of 77% in diagnosing CBD stones, and IOC failed to detect two out of three BDIs. Moreover, IOC is associated with longer operative time and a higher cumulative complication rate.

Most surgeons in our center systematically perform IOC as recommended by the Fédération de Chirurgie Viscérale et Digestive. Indeed, among patients undergoing LC, 83.2% were scheduled for IOC. Our success rate was approximately 85.3%, confirming results reported in high volume centers (80.4%–98.9%) [6]. On the contrary, according to our experience, 14.7% of IOC are not been completed, but this failure rate may increase to 64% in small centers [13]. The main reason for failure is the difficult of introduction of cholangiography catheter into a small cystic duct. In our series, the patient had a case of cystic duct avulsion without significant consequences. Similar complications were reported by Amott et al. [13] and the BDI case concerning IOC executions. Therefore, the IOC has been a complicated process at times.

Another area for clarification about cholangiogram interpretation is that it depends on the surgeon’s experience. Regarding BDI identification, IOC allowed us to identify only one case in our series, already strongly suspected by the surgeon. We had false-negative cholangiograms and biliary duct stricture after normal IOC. Fletcher et al. [14] showed that anatomy was correctly interpreted in less than 25% of IOCs BDI occurred. Rhaiem et al. [15] suggested performing a systematic MRCP before planning LC to identify “dangerous” anatomic variations and prevent BDI. In theory, this is a desirable solution. However, in actual practice, it is difficult to perform a preoperative MRCP procedure on every patient for several reasons: (1) there are still centers with difficult access to MRCP; and (2) specific skills are required for the interpretation of biliary anatomy on your own; moreover, in most cases, cholecystectomy is performed by surgeons without a real hepatobiliary surgical expertise.

To identify CBD stones, Ford et al. [6], in their systematic review of 8 randomized trials and 1,715 patients, found 24 false-positive cholangiograms. Moreover, in the trials included in the systematic review, the use of IOC did not demonstrate any specific benefit in detecting CBD stones.

Consequently, our data and literature show that IOC interpretation can be challenging to identify BDI or CBD stones.

In case of strong suspicion of CBD stones, we performed a preoperative MRCP. The no-IOC group had preoperative MRCP (30.7% vs. 17.2%), which allowed the identification of 5% of patients with CBD stones. Our results, according to the literature, suggest that preoperative ERCP is an effective and safe tool for evaluating the biliary tree when CBD stones are suspected [16]. Nevertheless 10% to 20% of patients undergoing LC have CBD stones without clinical symptoms or laboratory abnormalities [17]. In this case, the systematic execution of IOC to identify CBD stones is useful. However, there is no unanimous, and the treatment of asymptomatic stones is unclear: the British Society of Gastroenterology recommends their systematic removal [18], suggesting a conservative approach, because of the risk for complications of ERCP [19].

More recently, two other surgical societies have joined forces against the systematic execution of the IOC [20,21]. The Institut de Recherche sur les Cancers de l’Appareil Digestif recommendations on safe LC do not consider the implementation of formal IOC to prevent BDI due to sufficient robust scientific evidence; conversely, IOC is recommended to define unclear anatomy [20]. In this sense, the World Society of Emergency Surgery does not recommend the systematic implementation of IOC for the same reasons, and BDI may occur after IOC misinterpretation [21].

Rystedt et al. [5] address the recent meta-analysis that included eight studies and more than two million patients. The risk of BDI was estimated to be 0.36% vs. 0.53% depending on whether IOC was routine or elective, respectively, suggesting that conventional IOC reduces the risk and prevents BDI in LC. However, several limitations are associated with this study: only significant but retrospectives articles were included, no randomized studies were analyzed, and the criteria of the selected IOC were not adequately investigated.

A randomized study involving 371 patients failed to demonstrate a real advantage of the systematic use of IOC in preventing BDIs or identifying CBD stones [7].

Indocyanine green fluorescence cholangiography (ICG-C) can be a valid alternative to IOC.

ICG-C can identify biliary tree anatomy without adding the additional time and expertise required for IOC [22].

In a randomized study, ICG-C was confirmed to be non-inferior to IOC in identifying biliary anatomy during LC [23]. In another recent randomized study involving 639 patients, Dip et al. [24] reported that the use of ICG-C is statistically superior to classical vision in recognizing extrahepatic biliary structures. ICG-C appears to be a promising tool, but there are some limitations of its systematic use: (1) the need for an appropriate camera; (2) the optimal timing of ICG injection is still debated; (3) ICG-C may fill in certain types of patients, for example, due to visceral adiposity [22]. Nonetheless, the increasing use of fluorography in the colorectal and hepato-biliary surgery could make ICG-C more accessible in the near future.

Our series found a higher overall complication rate in the IOC group (5.1% vs. 0.0%, p = 0.03). One trial, including open cholecystectomies, reported significantly higher morbidity in the IOC group, and another study reported slightly higher surgical site infection in the IOC group [25,26]. The morbidity rate related to IOC is not very detailed in the literature, and there is a lack of data [6].

This study has several limitations: retrospective and single-center study, limited study population size, and procedures performed by young and highly trained surgeons.

In conclusion, routine implementation of IOC during elective LC increased operative time and overall postoperative morbidity without demonstrating a real benefit in the early detection of BDI or CBD stones. The confounding of systematic or selective use of IOC is still unresolved, and further randomized studies are needed.

FUNDING None.