Role of selective intra-operative cholangiography during cholecystectomy

Background: The use of routine intra-operative cholangiography (TOC) remains controversial. This prospective study was carried out to determine whether to perform selective or routine IOC in patients undergoing cholecystectomy for gallstones. Methods: All consecutive patients undergoing open cholecystectomy over a 16-month period were included in the present study. They were divided into two groups based on the absence (n = 79) or presence (n = 55) of indicators of choledocholithiasis. All patients were subjected to cholangiography. Each indicator, subsets of indicators and all indicators combined were evaluated for their ability to predict choledocholithiasis. Results: There would be only two missed stones (1.5%) if selective cholangiography was to be practised. Intra-operative cholangiography had a positive predictive value of 100%. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of all the indicators combined were 93.5%, 84.6%, 74.5%, 97.5% and 88.0%, respectively. The best indicators in each subset were jaundice, common bile duct diameter as assessed by ultrasonography, and a palpable stone during surgery with NPV of 82.7%, 91.1% and 96.8%, respectively. Conclusion: Routine IOC during cholecystectomy is not essential for the prevention of retained stones. A combination of the various indicators of choledocholithiasis can be used to select patients for cholangiography.