A reliable method for handling the "difficult" cystic duct to obtain a good cholangiogram during laparoscopic cholecystectomy.

BACKGROUND: Intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) is used to assess the anatomy of the biliary tree and to detect any stones contained within it. Intraoperative cholangiography may be performed either routinely or more selectively in cases where there is a high suspicion of choledocholithiasis or for those patients whose anatomy appears unclear at operation [8]. In cases where significant inflammation is present, the cystic duct may be short, thickened, or dilated and thus difficult to manipulate to obtain a satisfactory IOC.
METHODS: We describe a safe, simple, reliable technique to control the "difficult" cystic duct during IOC with a vascular vessel loop instead of a surgical clip to obtain good control and avoiding extravasation of dye during IOC. The feasibility, safety, and results of this technique are described.
RESULTS: During a 1-year period, this technique has been used in 10 patients, and it was successful in all attempted cases, with a good quality IOC obtained on the first attempt. The cystic duct was then occluded in all cases using a Vicryl "0" endoloop. One patient had a common bile duct stone and this patient received postoperative endoscopic retrograde pancreatography (ERCP). All patients were discharged home with no complications. In cases where a short, thickened, or dilated cystic duct was present, ductal control during IOC was easily obtained using a vascular vessel loop.
CONCLUSIONS: This is a safe, reliable, less traumatic, readily available, and inexpensive method that provides a secure way of handling the "difficult" cystic duct.