Laparoscopic ultrasound as the primary method for bile duct imaging during cholecystectomy

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Abstract
Intraoperative fluorocholangiography (IOC) has been the standard method for bile duct imaging during cholecystectomy. Laparoscopic ultrasound (LUS) has been evaluated as a possible alternative, but has been used less frequently. The authors examined the evolving use of these two methods to assess the relative utility of LUS as the primary method for routine bile duct imaging during laparoscopic cholecystectomy (LC). This study analyzed a prospective database containing 423 consecutive cholecystectomies performed by one attending surgeon in an academic medical center between 1995 and 2005. Intraoperative bile duct imaging was performed in 371 (94%) of 396 LCs performed for cholelithiasis. As recorded, IOC was performed in 239 cases, LUS in 236 cases, and both in 104 cases. Choledocholithiasis was present in 50 patients (13%). Common bile duct stones (CBDS) were identified by LUS in 3% of the patients without preoperative indicators of CBDS, and in 10% of the patients with one or more indicators. As shown by the findings, LUS had a positive predictive value of 100%, a negative predictive value of 99.6%, a sensitivity of 92.3%, and a specificity of 100% for detecting CBDS. Also, LUS identified clinically significant bile duct anatomy in 6% of the patients. In 1995, LUS was used for 20% of cases, whereas by 2005, it was used for 97% of cases. Conversely, the use of IOC decreased from 93% to 23%. With moderate experience, LUS can become the primary routine imaging method for evaluating the bile duct during LC. It is as reliable as IOC for detecting choledocholithiasis. In addition, LUS can locate the common bile duct during difficult dissections. On the basis of this experience, LUS is used currently in nearly all LCs and is the sole method for bile duct imaging in 75% of these cases. IOC is used as an adjunct to LUS when LUS imaging is inadequate, when stronger clinical indicators of choledocholithiasis are present, or when biliary anatomy remains uncertain.

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