Performance and interpretation of intraoperative cholangiography and the role of selective vs. routine intraoperative cholangiography: a narrative review

Introduction

Intraoperative cholangiography (IOC) can be used during a cholecystectomy to delineate biliary anatomy in real time and therefore guide intervention as needed (1-4). In this review, we will specifically be referring to cholangiography using fluoroscopy. IOC can be performed selectively or routinely. The purpose of this article is to review indications and benefits of IOC, ways to perform the procedure, and alternatives to IOC. We will also compare the selective and routine use of IOC.

Background

Despite wide utilization of laparoscopy, bile duct injuries remain a complication with increased risk of morbidity and mortality for patients (5-8). IOC has emerged as a diagnostic and therapeutic technique for patients with bile duct injuries as well as retained stones or aberrant anatomy (7,9,10).

Rationale and knowledge gap

The routine use of IOC compared to selective use in laparoscopic cholecystectomies has been debated over time. Selective cholangiography reduces operative time and resource utilization. However, routine use allows for not only visualization of the biliary tree for diagnostic purposes, but also the therapeutic ability of IOC should a pathology be discovered. Recently, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has recommended in favor of routine IOC (11), suggesting the risk and benefits of routine use should be reconsidered.

Objective

Our purpose is to perform a thorough review of the literature to describe IOC performance, interpretation, and alternatives, as well as compare routine and selective use. Based on the literature, we aim to provide recommendations on the frequency of IOC use. We present this article in accordance with the Narrative Review reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-57/rc).

Methods

A thorough literature review using Google Scholar and PubMed was performed. Articles included were from the years 1990 to September 2025 in order to capture the history of IOC as well as current practices. Literature was reviewed between the dates of 8/18/2025–8/20/2025, and an additional search was performed on 10/6/2025 to ensure up-to-date information on the SAGES guidelines prior to publication. A search was performed on 1/21/2026 to provide more background information on alternative practices. Search terms included “intraoperative cholangiogram”, “selective cholangiogram”, “routine cholangiogram”, “cholangiogram interpretation”, “laparoscopic ultrasound”, “robotic cholecystectomy cholangiogram”, “light cholangiography”, “near-infrared fluorescence cholangiography”. Articles published in English were included. Article types included original research articles, systematic reviews, meta-analyses, clinical spotlight reviews, expert statements, and clinical practice guidelines. To capture a general knowledge of IOC and its history, articles that explored methods of IOC use, historical patterns of IOC use, opinions on routine and selective IOC, and comparison of routine and selective use were included. Case reports were not included (Table 1).

Literature findings

Background and purpose of IOC

Laparoscopic cholecystectomies are now one of the most common abdominal surgeries performed worldwide after their introduction in the 1980s (5,8,12). The laparoscopic approach was being adopted due to its shortened length of stays, reduced operative times, and its favorable cosmetic results. However, the introduction of this new surgical technique presented challenges for surgeons as they honed their laparoscopic skills. One of the results was the increase in bile duct injuries, reported to increase from 1:1,000 to 1:100 during this transition (13).

Over the years, as laparoscopy was more widely adopted, bile duct injuries decreased. However, the incidence of injury remains 0.3–1.5% (5,7,8). Bile duct injuries affect the quality of life for patients, increase the financial burden for the healthcare system, and most importantly increase mortality (6,7). Treatment for severe bile duct injuries includes invasive and life-changing surgeries, typically a Roux-en-Y hepaticojejunostomy and, in extreme cases, liver transplantation (8). Common bile duct (CBD) injuries are addressed more thoroughly in an earlier chapter. However, despite the transition to laparoscopy, the most likely cause of injury during a cholecystectomy remains poor visualization of the biliary system (5). IOC offers a possible solution to this error and therefore serves as a preventative tool against bile duct injuries (14).

As discussed, the purpose of the IOC is to delineate biliary anatomy. The intention is to reduce the incidence and severity of bile duct injuries (9,10,15). In addition to this important purpose, IOC can detect residual stones within the biliary tree that could increase risk of jaundice, pancreatitis, or sepsis in patients after laparoscopic cholecystectomy if they are missed (7,10,16). This also reduces the need for postoperative endoscopic retrograde cholangiopancreatography (ERCP) or reoperation (9).

Procedure

Preparation prior to IOC should include an operating room set up that is conducive to the use of imaging and confirmation of all needed supplies including contrast, flushes, and the instrument of choice for introduction of the cholangiography catheter. In an ideal or routine laparoscopic cholecystectomy, for example, an elective procedure with little inflammation or scar tissue, the first operative step is obtaining the critical view of safety (17). The critical view of safety is a systematic dissection that delineates Calot’s triangle (5). This provides a clear path for the next steps for cholangiography. Ideally, a small ductotomy is made in the anterior surface of the cystic duct for the introduction of the cholangiography catheter (17). A clip may be placed proximally on the cystic duct near the gallbladder infundibulum to prevent reflux of contrast into the gallbladder or spillage of bile. If anatomy is unclear, dissection is difficult, or injury has already occurred, there are other options for introduction of the cholangiography catheter. This includes direct placement into the gallbladder or through the injury, if present, which can be easily identified by the leakage of bile from the site.

After a site has been created, the catheter must be inserted for the introduction of contrast into the biliary system. There are numerous catheters and tools that allow access to the biliary system; ideally, the catheter will be 5 French or greater in size to allow the introduction of guidewires and other tools for possible intervention (17,18). Once the catheter is in place, it should be secured either with a clip, balloon, or cystic duct holding device (17). The imaging equipment (C-arm or X-ray) should then be positioned over the patient’s right upper quadrant from the left side, as this allows for direct entry into the biliary system (17). The diluted dye is then injected into the biliary system as fluoroscopic images are obtained (17). Live fluoroscopic images are preferred to static films if available.

Radiographic interpretation

The interpretation of the IOC is the most important step in the process. Cholangiograms can be read in real time by the surgeon performing the procedure or by a radiologist (19,20). Being read by the surgeon can save time and resources, as not all centers will have a radiologist available to read the cholangiogram in a timely manner. Normal anatomy should show contrast in the intrahepatic and extrahepatic biliary anatomy without variations, no biliary dilation, no filling defects, and contrast should flow into the duodenum. Anatomic variants include drainage of the right posterior duct into the left hepatic duct or common hepatic duct, and trifurcation of the right anterior duct, right posterior duct, and left hepatic ducts (6).

Abnormal cholangiograms can be due to disease or improper placement of the IOC catheter. CBD dilation, which is dependent on age, may indicate downstream obstruction. Filling defects can be due to strictures, stones, or, less commonly, neoplasms (21). Filling defects can also be due to bubbles in the biliary system, which is why assurance that the syringe is without bubbles before contrast administration is important. However, if bubbles are suspected, the cholangiography system can be flushed with saline, followed by re-administration of dye and additional images. A lack of contrast in the duodenum may be similarly due to strictures, stones, or neoplasms; however may also be caused by sphincter of Oddi inflammation or spasms (22). One way to differentiate between a structural obstruction and a spasm is to administer glucagon to the patient, re-administer contrast and take additional images.

Misplacements of the catheter can lead to abnormal results, including accidental cannulation of the cystic artery or division of the common hepatic duct with the catheter inserted into the CBD (6). Contrast extravasation may represent injury to the biliary system or dislodgement of the catheter. If the duodenum fills with contrast but there is no intrahepatic filling, the catheter may be too deep or may be in the CBD as opposed to the intended cystic duct. To troubleshoot this, the catheter can be pulled back, the patient positioned in Trendelenburg, and morphine may be administered to increase sphincter of Oddi spasm to prevent flow into duodenum. If there is still no intrahepatic flow, an injury to the common hepatic duct should be considered.

Alternatives

There are several alternatives to IOC including light cholangiography, near-infrared fluorescence cholangiography, laparoscopic ultrasound (LUS), and indocyanine green (ICG) (5).

LUS is the use of color Doppler to visualize the CBD, portal vein, and hepatic artery. When performed, the color Doppler generates the characteristic “Mickey Mouse” appearance of these three structures (5). There are several meaningful benefits to LUS. LUS is quicker, less invasive, and more cost-effective. Because there is no introduction of air into the system, air bubbles cannot be misidentified as stones and therefore there is a lower false positive rate. It is also a good alternative for patients wishing to avoid irradiation, which is especially beneficial for pregnant patients. LUS can be used before and after dissection of the critical view of safety, allowing confirmation of anatomy. It can also visualize adjacent anatomy such as the cystic and hepatic arteries (5).

LUS may be considered as an adjunct to IOC as well, as it may provide clearer identification of the CBD in cases of patients with cholangitis or prior pancreatitis causing inflammation. Disadvantages of LUS include its steep learning curve for surgeons and overall the success of its use is user-dependent. It is also difficult to visualize the intra-pancreatic biliary anatomy compared to IOC (5). There is an added cost to LUS as well in order to have LUS probe available. Perhaps most importantly, LUS is purely diagnostic with no access to the biliary tree, and therefore not therapeutic like IOC.

Another frequently discussed alternative is ICG. This is a hydrophilic fluorescent dye that binds to albumin in plasma and alpha-1 lipoprotein. It is exclusively eliminated by the liver. Its peak concentration in the bile is at 30 minutes to 2 hours, whereas peak concentration in the arterial system is one to 2 minutes. The dye can be administered intravenously preoperatively or directly into the gallbladder. After administration, the laparoscope is changed to infrared view to allow identification of biliary anatomy (10,23).

Several benefits of ICG have been described. The procedure is not invasive with no need for cannulation or dissection, takes up minimal operative time, and is low-cost. Additionally, it is effective in patients with acute cholecystitis, obese patients, and safe for pregnant patients. There is no steep learning curve like what is described for LUS and IOC. It has also been suggested as an adjunct to IOC, similar to LUS. Disadvantages include anaphylaxis, possible compromised use in patients with liver dysfunction, inability to identify stones, and the limited use as a diagnostic tool without biliary tree access and therefore no therapeutic benefit (10).

Light cholangiography and near-infrared fluorescence cholangiography are less commonly used compared to LUS and ICG. In light cholangiography, an optic fiber is used endoscopically and passed through the ampulla of Vater to illuminate the biliary tree. Although this modality avoids invasive ductotomy, it requires the additional time and equipment needed to complete ERCP. The use of ERCP also comes with any complications of ERCP, such as pancreatitis (24). Near-infrared fluorescence cholangiography uses a laser along with intravenous fluorescent dye, such as ICG, to assess biliary anatomy. A benefit is that it is not invasive beyond the intravenous injection of ICG. However, it requires expensive cameras which limit its availability, especially in non-elective cases (12). Similar to LUS and ICG, it is a purely diagnostic tool and not therapeutic.

Selective vs. routine IOC

Selective and routine IOC use has been debated since its introduction to clinical practice, with some questioning its benefit when weighed against the use of time and resources. In the 1990s to early 2000s, IOC was strongly recommended given the rising incidence of CBD injury with the adoption of laparoscopic cholecystectomy (2,9,25-27). However, in the 2010s, the consensus became more mixed as some research began to suggest there was no evidence for the use of routine IOC (14,28-34). Since the 2020s, more evidence of IOC improving outcomes has been reported (3,8,35-39). More recently, the SAGES has recommended in favor of routine IOC (11). We will review the reasoning behind both selective and routine IOC below.

Selective IOC is performed based on several indications. These include patient history and condition, such as presence of jaundice, elevated liver function tests (LFTs), or history of gallstone pancreatitis (3,17,40,41). The decision to perform IOC may also be based on the patient’s surgical history. This includes a history of gastric bypass, which may make future interventions for missed stones, such as ERCP, difficult. It may also be based on preoperative imaging findings, including a CBD larger than 5–7 mm (based on age), a cystic duct greater than 3 mm, evidence of CBD stones or multiple small gallbladder stones. Intraoperative considerations include unclear anatomy, concern for bile duct injury, or a short cystic duct (3,17).

Supporters of selective IOC point to decreased operative time, less resource utilization, and less dissection needed since no cannulation is planned (5,42). It also requires additional training for the surgeons and their surgical team. Literature has shown that selective IOC is more commonly performed by low volume, academic surgeons, suggesting that limited opportunity to practice may contribute to selective use (7,13,43).

In contrast, routine IOC is often performed by high volume, non-academic surgeons (13,43). Routine IOC is advocated for based on many factors, including its reduction in morbidity related to bile duct injuries or retained stones (3,36). When compared directly with selective IOC, routine IOC has been shown to have lower rates of bile duct injuries, higher rates of CBD stone detection, and fewer postoperative ERCPs (32). It has been estimated that routine IOC may prevent 2.5 deaths per 10,000 cholecystectomies (8). Because of this reduced morbidity, there is also an argument that it is less financially burdensome as it avoids the cost of treating severe bile duct injuries with reoperation or working up retained stones postoperatively (3,9).

However, there are hurdles to routine use. One major barrier is the resources needed to perform IOC. This includes equipment for the procedure itself, operating room staff who are knowledgeable of the procedure, and access to a C-arm. Additionally, interpretation of the IOC has several limitations. It may add time to the procedure if a radiologist’s read is needed. This also means that centers must have a radiologist available for interpretation. Time spent on interpretation can be saved if the IOC is read by the surgeon intraoperatively; however, this requires additional experience and varies greatly between surgeons (4,44).

As mentioned, those who perform IOC routinely are often high-volume surgeons with more practice using this technique. Lower volume surgeons may have less opportunity to practice this skill. If these lower volume surgeons are practicing in an academic setting, this has a downstream effect on medical training by decreasing the opportunity and expertise to train future surgeons on the use of IOC. This results in a new generation of surgeons lacking this skill. A recent article confirms a significant decline in IOC performance and training in the last 10 years (43).

The use of robotic surgery has been increasing and one study found that robotic cholecystectomies in particular increased 37-fold from 2010 to 2019 (45). The adoption of robotic cholecystectomies also contributes to the lack of training for future surgeons. IOC can be a hassle to perform in these cases since it requires undocking and redocking the robot. Additionally, the technical aspects of IOC may be more difficult for surgeons who have limited laparoscopic training for cholecystectomies (45-50).

Both the lack of experienced mentors and the increase in robotic surgery training may contribute to a barrier in IOC training for new surgeons. By integrating IOC as a required procedure in general surgery resident case logs, this will push for the inclusion of IOC in academic centers. Additionally, the routine use of IOC by experienced surgeons will provide more opportunities for trainees to learn the skill prior to entering into practice.

Routine use of IOC will present a transitional challenge for surgeons with low volume, much like the transition from open cholecystectomies to laparoscopic cholecystectomies. However, once this is overcome, patients will benefit from decreased morbidity and mortality associated with bile duct injuries and retained stones. Additionally, trainees will benefit from the increased exposure during residency. It will be interesting to evaluate changes in routine use after the new SAGES guidelines. Future studies could compare routine IOC rates before and after the guidelines were published.

Conclusions

There are risks and benefits to the use of IOC during laparoscopic cholecystectomies. The authors are proponents of routine visualization of biliary anatomy during laparoscopic cholecystectomy and recommend IOC as the preferred modality based on the senior author’s 30 years of experience utilizing routine IOC and this literature review. In particular, we recommend routine IOC as it not only provides clear views of the biliary anatomy, but can serve as a therapeutic modality as well. However, there are benefits to selective compared to routine use including reduction in operating time and less resource utilization. Overall, we would advocate for frequent instruction of IOC for surgical trainees beginning early in their residency.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Laparoscopic and Endoscopic Surgery for the series “Laparoscopic and Endoscopic Management of Advanced Benign Biliary Pathologies”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-57/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-57/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-57/coif). The series “Laparoscopic and Endoscopic Management of Advanced Benign Biliary Pathologies” was commissioned by the editorial office without any funding or sponsorship. J.M. served as an unpaid Guest Editor of the series and serves as an unpaid editorial board member of Annals of Laparoscopic and Endoscopic Surgery from June 2025 to May 2027. J.M. is a consultant for Boston Scientific and Steris Endoscopy. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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