Intraoperative ultrasound as an educational guide for laparoscopic biliary surgery

Table 1 Patient demographic data

	Before routine IOUS (1991-1997)	Routine IOUS (1998-2006)	P
Patient number (n)	368	276
Male/Female	140/228	107/169	0.85
Age (yr)	53.3 ± 13.9	57.1 ± 13.6	0.004
Operative indications, n (%)			0.73
Cholecystolithiasis	296 (80.4)	228 (82.6)
Cholecystocholedocholithiasis	39 (10.6)	23 (10.5)
Choledocholithiasis	7 (1.9)	4 (1.4)
Gallbladder polyp	22 (6.0)	11 (4.0)
Others1	4 (1.1)	4 (1.4)
Symptomatic gallstones, n (%)	284 (77.2)	220 (79.7)	0.44
Acute cholecystitis/cholangitis, n (%)	42 (11.4)	32 (11.6)	0.94
Bile duct diameter2 (mm)	8.9 ± 4.2	8.4 ± 3.6	0.12

¹Other benign processes including chronic cholecystitis and adenomyomatosis, which need whole biopsy of the gallbladder for suspected malignancy.

²Maximal dimension of the extrahepatic bile duct was measured by drip infusion cholangiography (51%), endoscopic retrograde cholangiography (35%), percutaneous transhepatic cholangiography (4%), magnetic resonance cholangiography (2%), and/or extracorporeal ultrasonography (8%).

Table 2 Various operations before and after routine IOUS

	Before routine IOUS (n = 368)	Routine IOUS (n = 276)	P
Surgeon, n (%)
Senior (≥ 100 cases)	341 (92.7)	77 (27.9)	< 0.0001
Junior (< 30 cases)	27 (7.3)	199 (72.1)
Intraoperative image studies, n (%)
Ultrasound	68 (18.5)	231 (83.7)	< 0.0001
Cholangiography	45 (12.7)	25 (9.1)	0.14
Anatomical variations of the bile ducts, n (%)	10 (2.7)	12 (4.2)	0.26
Laparoscopic cholecystitis grading, n (%)
G0	203 (55.2)	166 (60.1)	0.03
G1	59 (16.0)	40 (14.5)
G2	72 (19.6)	33 (12.0)
G3	34 (9.2)	37 (13.4)
Conversion to open surgery, n (%)	6 (1.6)	15 (5.4)	0.007
BDI	2	0	0.27
Severe cholecystitis	2	4
Cholecystoduodenal fistula	0	1
Access failure due to dense adhesion	1	5
Cancer suspected	1	1
Systemic co-morbidity	0	3
Total laparoscopic procedures, n (%)	362 (98.4)	261 (94.6)	0.007
Cholecystectomy	317 (87.6)	235 (90.0)	0.34
Cholecystectomy and choledocholithotripsy	45 (12.4)	26 (10.0)
Operative time1 (min)	93.7 ± 53.1	116.7 ± 49.7	< 0.0001
Cholecystectomy	80.6 ± 36.2	109.4 ± 42.1	< 0.0001
Cholecystectomy and choledocholithotripsy	185.4 ± 62.0	187.6 ± 61.2	0.88
Blood loss1 (g)	16.9 ± 75.5	14.1 ± 53.2	0.6
Cholecystectomy	10.1 ± 42.8	15.1 ± 55.4	0.23
Cholecystectomy and choledocholithotripsy	65.1 ± 175.4	4.2 ± 20.4	0.1

¹In cases treated with total laparoscopic procedures.

Table 3 Factors determining operation time of LC

Factors	F value	P value
Use of IOUS	6.524	0.011
Operative indication	1.071	0.370
Presence of cholecystitis symptom	2.381	0.123
Surgeon (senior/junior)	3.778	0.053
Intraoperative cholangiography	1.685	0.195
LCG: G0/G1/G2/G3	5.148	0.002
IOUS × Surgeon	0.208	0.648
IOUS × LCG	0.359	0.782
Surgeon × LCG	0.424	0.736

Table 4 Early and late results

Outcome	Before routine use (n = 368)	Routine use (n = 276)	P
Early complication, n (%)
BDI	4 (1.1)	0	0.08
Arterial bleeding requiring clips	9 (2.4)	5 (1.8)	0.59
Postoperative bleeding	2 (0.5)	1 (0.4)	0.74
Surgical site infection	1 (0.3)	1 (0.4)	0.84
Re-operation	11 (0.3)	12 (0.4)	0.84
Hospital death	13 (0.3)	0	0.39
Postoperative treatment for duct stone	74	25	0.19
Hospital stay (d)	5.4 ± 5.7	4.4 ± 2.6	0.006
Late complication (> 1 yr), n (%)
Bile duct recurrence	1 (0.3%)	0	0.39
Bile duct stricture	0	0	-

¹Open hemostasis of postoperative bleeding from the liver bed;

²Laparoscopic hemostasis of a small arterial bleeding at the port site;

³Brain stem infarct on POD 4;

⁴All treated with percutaneous cholangiofiberscopic lithotripsy through preoperatively-established sinus tracts;

⁵Both treated with endoscopic sphincterotomy.

Table 5 BDI during LC

	Age (yr)/gender	Indication	Anatomical variation	LCG	Type of injury	Repair
1	58/female	Cholecystolithiaisis	+1	2	Cutting of the common hepatic duct	Hepaticojejunostomy (Roux-en-Y)
2	43/female	Cholecystolithiaisis	-	0	Cutting of the common hepatic duct	Hepaticojejunostomy (Roux-en-Y)
3	86/female	Chronic cholecystitis (cancer suspected)	+2	0	Cutting of the posterior branch of the right hepatic duct	Duct-to-duct anastomosis using an internal stent
4	63/female	cholecystocholedocholithiais	-	3	A small tear of the common hepatic duct at the dense adhesion to the neck of the gallbladder	Simple suture

¹The cystic duct ran behind the common hepatic duct and connected with it at the left lateral wall near the pancreas;

²The cystic duct joined the posterior branch of the right hepatic duct.

Table 6 Diagnostic accuracy of IOUS (%)

	Sensitivity		Specificity		PPV		NPV		Overall accuracy
	Pre-op	IOUS	Pre-op	IOUS	Pre-op	IOUS	Pre-op	IOUS	Pre-op	IOUS
Anatomical variation	25	100	100	100	100	100	96	100	96	100
Cholecystolithiasis	99	100	100	100	100	100	87	100	99	100
Bile duct stone	76	76	100	99	100	93	95	95	96	95
Polyps	77	82	98	98	77	75	98	99	97	97
Others	50	81	93	95	70	82	86	94	83	92

PPV: Positive predictive value; NPV: Negative predictive value; Pre-op: Preoperative image studies; Anatomical variation: Anatomical variation of the extrahepatic bile duct. Preoperative image studies included extracorporeal ultrasonography (100%), computed tomography (73%), endoscopic retrograde cholangiopancratography (51%), drip infusion cholangiography (42%), magnetic resonance cholangiopancreatography (20%), and/or percutaneous transhepatic cholangiography (5%).

Table 7 Ultrasonographic visualization of the biliary and arterial structures according to the laparoscopic cholecystitis grading (%)

	G0	G1	G2	G3	P value
Gallbladder	100	100	100	100	-
Cystic duct	100	95.6	100	91.4	0.001
Bifurcation	97.1	95.6	93.3	88.6	0.15
Common hepatic duct	99.4	95.6	97.8	88.6	0.003
Intrapancreatic bile duct	98.3	97.5	93.3	88.6	0.03
Right hepatic artery	100	97.5	100	89.3	0.0004