Editor’s note: The 14 ACS Advisory Councils, which act as liaisons between surgical societies and the Regents, periodically submit articles highlighting notable initiatives within their respective specialties.
This week’s issue features a submission from the Advisory Council for General Surgery.
The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guideline Committee recently published evidence-based guidelines on the intraoperative imaging of the common bile duct (CBD) during laparoscopic cholecystectomy for benign biliary disease. These guidelines are formed from a systematic review of available literature and expert panel evaluation and are intended as a conditional clinical guideline rather than a directive due to the low certainty of evidence for many outcomes.
A central focus of the guideline is the role of intraoperative cholangiography (IOC), particularly whether it should be performed routinely or selectively during elective cholecystectomy. Traditionally, many surgeons have adopted a selective use of IOC, employing it when there is suspicion of common bile duct stones, unclear anatomy in the operating room, or other specific operative or patient concerns.
However, the updated SAGES guideline suggests a shift toward routine IOC in all patients undergoing laparoscopic cholecystectomy, based on a synthesis of randomized trials and observational studies. Importantly, routine IOC is suggested over a selective approach, meaning that the guideline favors incorporating IOC as a standard part of the procedure rather than reserving it only for high-risk or anatomically difficult cases.
The rationale for this shift includes several potential benefits associated with routine IOC: better identification of aberrant biliary anatomy, improved intraoperative detection of previously undiagnosed CBD stones, reduced need for postoperative imaging and interventions, and a potential reduction in bile duct injuries. These outcomes, while not conclusively proven to occur in all settings, offer clinical advantages that the panel judged to outweigh harms and burdens such as slightly longer operative time and the need for intraoperative fluoroscopy equipment.
The guideline also compares IOC to other imaging modalities such as fluorescence imaging with indocyanine green (ICG) and laparoscopic ultrasound (LUS). IOC is suggested over imaging with ICG in most cases as ICG use does not evaluate the lumen of the ducts, though either IOC or LUS may be reasonable alternatives depending on surgeon preference and local resources.
Finally, the guideline emphasizes ongoing training and proficiency in IOC interpretation for general surgeons and trainees, as well as the need for further high-quality research to better define the effects of routine versus selective IOC.
