Abstracts
1997 Digestive Disease Week

The utility of intracorporeal ultrasonography for the screening of the bile duct during laparoscopic cholecystectomy.

IS Wu, DL Dunnegan, NJ Soper. Department of Surgery, Washington University School of Medicine, St. Louis, MO.

Introduction: Different strategies and imaging modalities have been used to detect common bile duct stones during laparoscopic cholecystectomy (LC). We prospectively compared fluoroscopic intraoperative cholangiogram (FIOC) and laparoscopic intracorporeal ultrasound (LICU) for this purpose in unselected patients undergoing LC. Methods: In a consecutive series of 582 LC's over a 4-yr period, FIOC was used in the first 407 patients while LICU was performed in the subsequent 175 patients. When LICU documented common bile duct stones, the duct was flushed with saline solution after intravenous administration of glucagon, and stone persistence or absence was confirmed by FIOC and/or repeat LICU. Results: In the FIOC group (mean ± SEM age = 49 ± 1 yrs; 104 M, 303 F), 11 patients were converted to open cholecystectomy and 22 patients did not undergo FIOC. In the remaining 374 cases, FIOC was successful in 363 patients (97%). In the LICU group (49 ± 1 yrs; 42 M, 131 F), 2 patients were converted and 25 patients did not undergo LICU for various reasons. In the remaining 148 patients, the cystic-common bile duct junction and the distal bile duct were visualized in all cases. The mean times required to complete FIOC and LICU were 16 ± 1 min and 5 ± 1 min, respectively (p < 0.0001). Choledocholithiasis was detected in 24 patients (7%) undergoing FIOC and in 19 patients (13%) undergoing LICU (p < 0.05). In the latter group, 79% of the stones were found in the terminal common bile duct and 21% were in the mid-duct. Maximal bile duct diameter ranged from 2-10 mm and was similar in those with (5.4 ± 0.5 mm) and without duct stones (4.7 ± 0.1 mm, p = 0.16). The mean size of the stones cleared by ampullary dilatation and flushing (14/19, 74%) and those requiring more invasive methods, i.e., laparoscopic bile duct exploration or ERCP, (5/19, 26%) were 1.6 ± 0.2 mm and 2.7 ± 0.3 mm, respectively (p < 0.01). Sludge was seen in the common bile duct by LICU in 7 (5%) patients, which disappeared with flushing in all cases. There was no morbidity associated with either FIOC or LICU; retained stones were not seen in either group. Conclusions: LICU is accurate, safe, and permits more rapid evaluation of bile duct stones than FIOC during laparoscopic cholecystectomy. LICU may be overly sensitive in detecting small stones and sludge, which are of questionable significance. Stones <= 2 mm can usually be cleared by flushing while larger ones often require duct exploration or ERCP for removal.