**7. Intraoperative cholangiography and common bile duct exploration**

## **7.1 Intraoperative cholangiography**

Intraoperative cholangiography (IOC) can be used intraoperatively for the identification of choledocholithiasis and for visualisation and identification of biliary tree anatomy. The common use of this technique is currently not recommended because of insufficient reduction in complication rate and BDIs during laparoscopic cholecystectomy [27]. The BDIs can appear even in patients in whom the IOC was performed, because of potentially incorrect interpretation of the findings [28]. However, it may be recommended in patients with difficult biliary anatomy and patients, in whom we are unable to perform critical view of safety or there is a perioperative suspicion of a BDI [28]. Importantly, the identification of BDIs with IOC may lead to earlier recognition with a quick therapeutic approach.

Alternatively, the use of indocyanine green fluorescence cholangiography (ICG-C) may be a good option for visualisation of the biliary tree [29]. This method has been suggested by some studies and proved to be effective in acute and chronic gallbladder diseases and in cases, where IOC cannot be used [30].

#### **7.2 Common bile duct exploration**

There is an ongoing controversy about an ideal solution for patients with gallstones and bile duct stones. Historically, the method of choice was the open cholecystectomy with the common bile duct exploration (CBDE), which was replaced due to the progress in the laparoscopic and endoscopic methods. With the improvement of the ERCP, the standard of care for patients with cholecystolithiasis and choledocholithiasis became the preoperative ERCP with the endoscopic sphincterotomy and extraction of the choledocholiths with the subsequent laparoscopic cholecystectomy [31]. It is important to say that the open CBDE was the gold standard during the era of the open cholecystectomies for patients in a need of bile duct stones extraction, with the ERCP being used secondarily. The improvements in the laparoscopy lead to a decline in OC and surgeons started to use and rely more on the ERCP to solve the choledocholithiasis. Laparoscopic CBDE is currently an advanced method and in some centres, it is a method of choice. Although some studies have shown the advantages (lower amount of interventions, lower economic burden, shorter length of stay) of the one-stage procedure (LC + laparoscopic CBDE) in comparison with two-stage procedures (pre- or postoperative ERCP + LC), this practice was not generally accepted [32]. Nowadays, the method of choice is twostage management with the preoperative ERCP and subsequent LC. Even though the ERCP is considered safe, it is a method with high chances of complications with acute post-ERCP pancreatitis being the most common post-ERCP complication with the high economic burden on healthcare systems [33].

Laparoendoscopic rendezvous (LERV) as a combination of laparoscopy and endoscopy is an attractive method in management of patients with cholecystolithiasis and choledocholithiasis. Recent meta-analysis of eight studies compared LERV with two-stage management (preoperative ERCP + LC) in 1061 patients with gallstones and bile duct stones [34]. A total of 542 patients were treated with LERV technique and 519 patients underwent ERCP with subsequent LC. Between the two groups there were no significant differences in the bile duct clearance (OR 2.20, P = 0.10), postoperative bleeding (OR 0.67, P = 0.37), postoperative cholangitis (OR 0.66, P = 0.53), postoperative bile leak (OR 0.87, P = 0.81), or conversion to different approaches (OR 0.75, P = 0.62) [34]. Total time of surgery was longer in the LERV group (MD = 44.93, P < 0.00001); however, the advantage of the LERV technique was lower incidence of postoperative pancreatitis (OR 0.26, P = 0.0003) and lower overall morbidity (OR 0.41, P < 0.0001) with a shorter length of hospital stay (MD = − 3.52, P < 0.00001) [34]. The authors of the meta-analysis concluded the LERV to be equivalent to standard two-stage management of patients with gallstones and bile duct stones [34].

In current practice, there are clear guidelines by the British Society of Gastroenterology recommending the extraction and clearance of the choledocholiths from the CBD [35]. Although, laparoscopic cholecystectomy is a gold standard for gallstone disease, a consensus on the optimal therapeutic approach in the management of bile duct stones has not been reached. Thanks to the improvements in the laparoscopic technique and surgical skills, the single-stage LC + CBDE has shown its benefits and promise. However, the very limitations are based on the necessity of advanced surgical skills with technical demandingness and the availability of the ERCP rule in favour of the two-stage approaches in the majority of centres [36]. The future may lie with the LERV technique, although as a novel therapeutic approach there are still needed further randomised control trials to decide the optimal therapeutic approach for patients with gallstones and bile duct stones.

### **8. Complications of gallstone surgical therapy**

Invasive procedures may be complicated by a number of factors related either to the surgeon and his skillset or patient's characteristics with the clinical findings and anatomical variations. In the case of laparoscopic cholecystectomy, the complications rate varies from 0.5 to 6%:


#### **Surgeon experience**

Incidence of complication is significantly related to the surgeon's experience. Some authors estimated 50 performed laparoscopic cholecystectomies to complete the training in this procedure. However, the end of the learning curve for laparoscopic cholecystectomy is somewhat debatable. Some studies have evaluated the decrease in the bile duct injuries or conversion and complication rates, while others focused on operation time, but the definitive criteria are still being formed [38]. Nonetheless, experienced surgeons have the lowest complication rates; therefore, an increasing number of institutions require proof of fundamental skills in laparoscopic surgery.

*Routine and Innovation in Surgical Therapy of Gallstones DOI: http://dx.doi.org/10.5772/intechopen.100570*

#### **Timing of surgery and patients selection**

Patients with acute cholecystitis with inflammatory changes have a higher likelihood for a complication during surgery. Also, a higher rate of complications can be expected in patients with chronic cholecystitis with fibrotic changes in the hepatoduodenal ligament and gallbladder fossa. Choledocholithiasis should be revealed before surgery. Patient's history and a series of examinations can refer to the presence of bile duct stones. Performing routine preoperative ERCP is not currently recommended [39]. It is reasonable only in cases of suspicion of common bile duct stones (dilatation of common bile ducts, clinical or laboratory picture of pancreatitis, fever, elevated inflammatory markers, jaundice).

#### **8.1 Biliary duct injury**

Clinical manifestation of biliary duct injury (BDI) can be various and it depends on the kind of injury. BDI can run asymptomatically in cases of small damages to the biliary tree to acute process in cases of transection or occlusion of the common bile duct. Approximately only 25% of cases of BDI are recognised during laparoscopy and the detailed description of the case is very important [40].

Type A—This group represents leakage from the gallbladder bed, minor hepatic ducts, and cystic duct without damage to the biliary tree (**Figure 5**).

Type B—Occlusion of the aberrant right hepatic duct (**Figure 6**).

Type C—Transection of the aberrant right hepatic duct (**Figure 7**).

Cystic dust drainage into an aberrant right hepatic duct is a variation seen in approximately 2% of patients. Injuries type B and C are usually caused by confusion of the aberrant right hepatic duct with the cystic duct. Patients with type B injury may remain asymptomatic for a long period of time. Right upper quadrant pain, fever, elevated liver enzymes, and markers of inflammation can be signs of cholangitis, and ultrasonography (US) will show dilatation of the right part of the biliary tree. The occlusion leads to dilatation of the right part of the biliary tree, fibrotic changes, and finally to lobar atrophy. Type C injury causes biliary leakage.

Type D—This group of injuries represents mural lesions of the common bile duct without interruption of its course (**Figure 8**). The result of this damage is a biliary leakage and it can progress to a more serious type E injury.

Type E—This injuries involve interruptions of the extrahepatic biliary ducts and depending on the location of the injury, they are divided into five subgroups (Bismuth classification) [39].

#### **Figure 5.**

*Schematic image of leakage from the gallbladder bed, minor hepatic ducts, and cystic duct without damage to the biliary tree (Type A).*

**Figure 6.** *Schematic image of occluded aberrant right hepatic duct (Type B).*

#### **Figure 7.**

*Schematic image of transected aberrant right hepatic duct (Type C).*

E1—(Bismuth Type I)—transection more than 2 cm from the confluence of the right and left hepatic ducts (**Figure 9**).

E2—(Bismuth Type II)—transection less than 2 cm from the confluence (**Figure 10**).

E3—(Bismuth Type III)—transection in the confluence (**Figure 11**).

E4—(Bismuth Type IV)— separation of major duct from the right and left hepatic duct (**Figure 12**).

E5—(Bismuth Type V)—Interruption of the aberrant right hepatic duct (Type C) combined with the injury in the hilum (**Figure 13**).

**Figure 8.** *Schematic image of lesion to the common bile duct without interruption of its course (Type D).*

**Figure 9.** *Schematic image of transected CHD (Type E, Bismuth Type I).*

Bismuth classification of BDI was the first scheme published in 1982 [41]. After this classification, other more complex classification systems were proposed. For clinical use, BDI are usually divided into two groups: minor and major injuries.
