Laparoscopic cholangiography. The case for a selective approach.

Intraoperative cholangiography has proved to be a significant benefit for the biliary surgeon by alleviating the morbidity of unnecessary common duct exploration in patients with suspected but unproved choledocholithiasis and by clarifying biliary anatomy in patients when dissection proves difficult. Laparoscopic surgeons should be capable of performing the procedure when indicated and should be comfortable interpreting the images obtained. Laparoscopic cholecystectomy with selective application of cholangiography can be performed with little or no effect on the incidence of retained calculi, with no impact on the incidence of common bile duct injury, and with diminished operative time and expense. The experienced laparoscopic surgeon can become facile with the procedure quickly and easily and does not require routine performance of the study to maintain these skills. Reduction of the incidence of biliary injury during laparoscopic cholecystectomy can be achieved by early meticulous dissection at the infundibular-cystic duct junction, with limited use of laser or electrocautery in this region rather than by reliance on intraoperative cholangiography.