Intraoperative Cholangiogram Interpretation for Laparoscopic Transcystic Bile Duct Exploration: Is Concurrence Possible?

Abstract

Background: Laparoscopic transcystic bile duct exploration (LTCBDE) represents a secure and efficacious approach for managing common bile duct (CBD) stones, particularly in patients concurrently undergoing laparoscopic cholecystectomy (LC). The decision to proceed with LTCBDE hinges on real-time assessment of the intraoperative cholangiogram (IOC), which is highly operator-dependent and poorly interpreted. No established criteria exist to guide the evaluation of IOCs for LTCBDE. This study aims to ascertain the concordance among surgeons, experienced in LTCBDE, on critical aspects of IOC interpretation.

Methods: A retrospective collection of IOC images of 40 patients who underwent LC, IOC, and LTCBDE at a tertiary university hospital between 2017 and 2018 was undertaken. Two hepato-pancreato-biliary (HPB) and 2 acute care surgery (ACS) specialists independently reviewed the images. They were tasked with assessing IOC features hypothesized to influence duct exploration and stone extraction complexity, along with overall suitability for LTCBDE based exclusively on the IOC images. Agreement percentages were calculated and Kappa inter-rater reliability statistics were assessed.

Results: The overall agreement percentages concerning IOC features ranged between 52.5% and 82.5% with agreements surpassing 75% deemed robust. Maximum agreement was achieved in the interpretation of cystic duct morphology, whether straight or characterized by spiral valves. The concurrence for amenability of LTCBDE also demonstrated substantial accord among surgeons (ACS: 92.5%, HPB: 95%, total: 87.5%). Consistently high agreement was evident within specialty groups.

Conclusions: Anatomical attributes displayed superior agreement levels, as opposed to variables necessitating measurements. We recommend the development of a structured approach for the interpretation of IOC to facilitate surgical education in LTCBDE.