Quality, clinical utility, and economic implications of routine intraoperative cholangiography during laparoscopic cholecystectomy: A standardised audit study

BackgroundLaparoscopic cholecystectomy (LC) is the standard treatment for gallstone disease, but routine intraoperative cholangiography (IOC) remains controversial regarding image quality and downstream resource use. This audit evaluated routine IOC performance, quality, clinical utility, and financial impact.MethodsA retrospective audit assessed 279 consecutive adults undergoing LC with attempted IOC (January-December 2024). Image quality was assessed using a novel 12-point checklist applied independently by three trained readers, with consultant adjudication of disagreements. Outcomes included IOC success, image quality, clinical findings, subsequent interventions, and costs.ResultsBiliary cannulation succeeded in 93.2% (260 out of 279) of cases, but only 66.92% (174 out of 260) met the pre-specified high-quality threshold (≥6 of 8 core parameters). Visualisation was lowest for the cystic duct junction and right sectoral ducts. Sixteen significant findings were identified, including 11 choledocholithiasis cases. No bile duct injuries occurred. Equivocal IOC-driven imaging led to 14 postoperative magnetic resonance cholangiopancreatographies, of which only five demonstrated pathology. Low-yield downstream imaging and prolonged admissions generated £11,800 in excess costs.ConclusionsRoutine IOC is feasible, but variable technical quality drives unnecessary downstream investigations and healthcare expenditure. Standardised reporting using a 12-point checklist can improve quality and resource utilisation.