Laparoscopic cholecystectomy

Population Covered By The Guidance

This pathway provides guidance on preoperative imaging of adult patients prior to laproscopic cholecystectomy.

Lead Researcher: Balaji Kodivalasa

Experts & Contributors: Drawn from Clinical Advisors
Link to Clinical Advisors

Editorial Panel: Core membership
Link to Editorial Panel

Date reviewed: January 2012

Date Published: January 2012

Image 1 (Ultrasound): Calculi in the gallbladder (green crosses).

Cholelithiasis

Image 2 (CT Cholangiogram): Three small filling defects (arrow) are seen within the common bile duct representing intraductal calculi.

Choledocholithiasis

Image 3 (ERCP): Gallstone present in the dilated common bile duct.

Choledocholithiasis

Image 4 (MRCP): Gallstone present in the dilated common bile duct (arrow).

Choledocholithiasis

Image 5: Cholecystectomy showing acute cholecystitis with gallbladder wall oedema, vascular congestion and purulent exudate (blue arrow) caused by a massive cholesterol stone.

Acute cholecystitis

Image 6 (H&E, x2.5): Histological section of severe acute cholecystitis showing extensive ulceration of the mucosa, haemorrhage, oedema and a dense transmural infiltrate of neutrophils and mononuclear inflammatory cells.

Acute Cholecystitis

  • The aim of investigation is to identify and treat patients with common bile duct (CBD) stones prior to surgery
  • Low probability of a stone - normal liver function tests (LFTs), normal CBD on ultrasound, previously abnormal LFTs or past history of pancreatitis
  • High probability of a stone - cholestatic jaundice, abnormal LFTs, abnormal CBD on trans-abdominal ultrasound or current episode of pancreatitis
  • If surgical expertise in laparoscopic cholecystectomy, intra-operative cholangiogram and laparoscopic stone removal is available proceed directly to this option
  • Non-invasive methods of evaluation include CT cholangiography, MR cholangiopancreatographyy and endoscopic US (EUS)
  • Endoscopic retrograde cholangiopancreatography (ERCP) enables retrieval of CBD stones prior to surgery

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

  1. Abboud PAC, Malet PF, Berlin JA, et al. Predictors of common bile duct stone prior to cholecystectomy: a meta-analysis. Gastrointest Endosc. 1996;44:450-9. (Level II evidence). View the reference
  2. Kama NA, Atli M, Doganay M, et al. Practical recommendations for the prediction and management of common bile duct stones in patients with gallstones. Surg Endosc. 2001;15:942-5. (Level II evidence). View the reference
  3. Berdah SV, Orsoni P, Bege T, et al. Follow-up of selective endoscopic ultrasonography and/or endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy: a prospective study of 300 patients. Endoscopy. 2001;33:216-20. (Level II evidence). View the reference
  4. Canto MI, Chak A, Stellato T, et al. Endoscopic ultrsonography versus cholangiography for the diagnosis of choledocholithiasis. Gastrointest Endosc. 1998;47:439-48. (Level II/III evidence)
  5. Stott MA, Farrands PA, Guyer PB, et al. Ultrasound of the common bile duct in patients undergoing cholecystectomy. J Clin Ultrasound. 1991:19:73-6. (Level II/III evidence)
  6. Sugiyama M, Atomi Y. Endoscopic Ultrasonography for diagnosing choledocholithiasis: a prospective comparative study with ultrasonography and computed tomography. Gastrintest Endosc. 1997;45:143-6. (Level II evidence). View the reference
  7. Amouyal P, Amouyal G, Levy P, et al. Diagnosis of choledocholithiasis by endoscopic ultrasonography. Gastroenterology. 1994;106:1062-7. (Level II/III evidence)
  8. Dong B, Chen M. Improved sonographic visualisation of choledocholithiasis. J Clin Ultrasound. 1987;15:185-90. (Level II/III evidence)
  9. Urbach DR, Khajanchee YS, Jobe BA, et al. Cost-effective management of common bile duct stones: a decision analysis of the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, and laparoscopic bile duct exploration. Surg Endosc. 2001;15:4-13. (Level III evidence)
  10. Cuschieri A, Lezoche E, Morino M, et al. E.A.E.S multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc. 1999;13:952-7. (Level II evidence). View the reference
  11. Neuhaus H, Feussner H, Ungeheuer A, et al. Prospective evaluation of the use of endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy. Endoscopy. 1992;24:745-9. (Level II/III evidence)
  12. Rieger R, Wayand W. Yield of prospective, noninvasive evaluation of the common bile duct combined with selective ERCP/sphincterotomy in 1390 consecutive laparoscopic cholecystectomy patients. Gastrointest Endosc. 1995;42:6-12. (Level II/III evidence)
  13. Rijna H, Borgstein PJ, Meuwissen SGM, et al. Selective preoperative endoscopic retrograde cholangiopancreatography in laparoscopic biliary surgery. Br J Surg. 1995;82:1130-3. (Level II/III evidence)
  14. Bergamaschi R, tuech JJ, Braconier L, et al. Selective endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy for gallstones. Am J Surg. 1999;178:46-9. (Level II evidence). View the reference
  15. Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996;335:909-18. (Level II evidence). View the reference
  16. Khandelwal N, Suri S, Malik M, et al. Ultrasound in choledocholithiasis. J Indian Med Assoc. 1991;89:95-7. (Level III evidence)
  17. Thornton JR, Lobo AJ, Lintott DJ, Axon AT. Value of ultrasound and liver function tests in determining the need for endoscopic retrograde cholangiopancreatography in unexplained abdominal pain. Gut. 1992;33:1559-61. (Level III evidence)
  18. Palazzo L, Girollet PP, Salmeron M, et al. Value of endoscopic ultrasonography in the diagnosis of common bile duct stones: comparison with surgical exploration and ERCP. Gastrointest Endosc. 1995;42:225-31. (Level II/III evidence)
  19. Prat F, Amouyal G, Amouyal P, et al. Prospective controlled study of endoscopic ultrasonography and endoscopic retrograde cholangiography in patients with suspected common bile duct lithiasis. Lancet. 1996;347:75-9. (Level II/III evidence)
  20. Aubertin JM, Levoir D, Bouillot JL, et al. Endoscopic ultrasonography immediately prior to laparoscopic cholecystectomy: a prospective evaluation. Endoscopy. 1996;28:667-73. ( Level II/III evidence)
  21. De Ledinghen V, Lecesne R, Raymond JM, et al. Diagnosis of choledocholithiasis: EUS or magnetic resonance cholangiography? A prospective controlled study. Gastrointest Endosc. 1999;49:26-31. (Level III evidence)
  22. Sahai AV, Mauldin PD, Marsi V, Hawes RH, et al. Bile duct stones and laparoscopic cholecystectomy: a decision analysis to assess the roles of intraoperative cholangiography, EUS, and ERCP. Gastrointest Endosc. 1999;49:334-43. (Level II/III evidence)
  23. Demartines N, Eisner L, Schnabel K, et al. Evaluation of magnetic resonance cholangiography in the management of bile duct stones. Arch Surg. 2000;135:148-52. (Level II/III evidence)
  24. Dwerryhouse SJ, Brown E, Vipond MN, et al. Prospective evaluation of magnetic resonance cholangiography to detect common bile duct stones before laparoscopic cholecystectomy. Br J Surg. 1998;85:1364-6. (Level II/III evidence)
  25. Soto JA, Alvarez O, Munera F, et al. Diagnosing bile duct stones: comparison of unenhanced helical CT, oral contrast enhanced CT cholangiography, and MR cholangiography. AJR Am J Roentgenol. 2000;175:1127-34. (Level III evidence)
  26. Polkowski M, Palucki J, Regula J, et al. Helical computed tomographic cholangiography versus endosonography for suspected bile duct stones: a prospective blinded study in non-jaundiced patients. Gut. 1999;45:744-9. (Level II/III evidence)
  27. Van Beers BE, Lacrosse M, Trigaux JP, et al. Noninvasive imaging of the biliary tree before or after laparoscopic cholesystectomy: use of three-dimensional spiral CT cholangiography. AJR Am J Roentgenol. 1994;162:1331-5. (Level III evidence)
  28. Hirao K, Miyazaki A, Fujimoto T, et al. Evaluation of aberrant bile ducts before laparoscopic cholecystectomy: helical CT cholangiography versus MR cholangiography. AJR Am J Roentgenol. 2000;175:713-20. (Level III evidence)
  29. O'Connor HJ, Hamilton I, Ellis WR, et al. Ultrasound detection of choledocholithiasis: prospective comparison with ERCP in the post cholecystectomy patient. Gastrointest Radiol. 1986;11:161-4. (Level II evidence). View the reference
  30. Cronan JJ. US diagnosis of choledocholithiasis: a reappraisal. Radiology. 1986;161:133-4. (Level III evidence)
  31. Griffin N, Wastle ML, Dunn WK, Ryder SD, Beckingham IJ. Magnetic resonance cholangiopancreatography versus endoscopic retrograde cholangiopancreatography in the diagnosis of choledocholithiasis. Eur J Gastroenterol Hepatol. 2003;15:809-13 (Level II evidence). View the reference
  32. Ledro-Cano D. Suspected choledocholithiasis: endoscopic ultrasound or magnetic resonance cholangio-pancreatography? A systematic review. Eur J Gastroenterol Hepatol. 2007;19(11);1007-11. (Level I/II evidence)
  33. Williams EJ, Green J, Beckingham I, Parks R, Martin D, Lombard M. Guidelines on the management of common bile duct stones (CBDS). Gut. 2008;57(7);1004-21. (Guidelines)

Further Reading

  1. Shah SK, Mutignani, Costamagna G, et al. Therapeutic biliary endoscopy. Endoscopy. 2002;34(1):43-53. (Review article)
  2. Palazzo L. Which test for common bile duct stones? Endoscopic and intraductal ultrasonography. Endoscopy. 1997;29:655-65. (Review article)

Pathway User Guide

Yellow Boxes Denotes extra information. Some contain single or multiple white sub-boxes, click a white box to reveal detailed information in a pop-up.

White Boxes: Denotes standard pathway steps. (If inside a yellow box, they open a specific pop-up).

Zoom & Pan Controls: Use + / − or the slider to zoom. Reset returns to default. Tick Panning to drag the diagram when zoomed.

Blue “View Full Screen” Button: Opens the whole diagram in a large, full-screen pop-up window. Use Close to exit.

The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.

SYMBOL RRL EFFECTIVE DOSE RANGE
No radiation None 0
Minimal radiation Minimal < 1 millisieverts
Low radiation Low 1-5 mSv
Medium radiation Medium 5-10 mSv
High radiation High >10 mSv

Disclaimer

Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.

Report an Issue

Spotted an error or outdated info? Click to tell us.

Liver and Biliary