ORIGINAL ARTICLE Intraoperative detection of aberrant biliary anatomy via intraoperative cholangiography during laparoscopic cholecystectomy Marthe Chehade,* Benedict Kakala,*† Jane-Louise Sinclair,* Tony Pang,*‡ Rafid Al Asady,§ Arthur Richardson,*‡ Henry Pleass,*‡ Vincent Lam,*‡ Emma Johnston,*‡ Lawrence Yuen*‡ and Michael Hollands*‡ *Upper Gastrointestinal/HPB Surgery, Westmead Hospital, Westmead, New South Wales, Australia †School of Medicine, Western Sydney University, Penrith, New South Wales, Australia ‡School of Medicine, The University of Sydney, Sydney, New South Wales, Australia and §Department of Radiology, Westmead Hospital, Westmead, New South Wales, Australia Key words anatomy, biliary, cholangiogram, cholecystectomy. Correspondence Professor Michael Hollands, Department of Surgery, Westmead Hospital, Hawkesbury Road, Westmead, NSW 2145, Australia. Email: michael. hollands@surgeons.org M. Chehade MBBS; B. Kakala MBBS; J.-L. Sinclair BN, GradCertSurgN; T. Pang FRACS; R. Al Asady FRANZCR; A. Richardson FRACS, FACS; H. Pleass MD, FRACS; V. Lam DClinSurg, FRACS; E. Johnston FRACS; L. Yuen FRACS; M. Hollands FRCS, FRACS. Accepted for publication 5 April 2019. doi: 10.1111/ans.15267 Abstract Background: Laparoscopic cholecystectomy (LC) is the standard of treatment for symp- tomatic cholelithiasis. Although intraoperative cholangiography (IOC) is widely used as an adjunct to LC, there is still no worldwide consensus on the value of its routine use. Anatom- ical studies have shown that variations of the biliary tree are present in approximately 35% of patients with variations in right hepatic second-order ducts being especially common (15–20%). Approximately, 70–80% of all iatrogenic bile duct injuries are a consequence of misidentification of biliary anatomy. The purpose of this study was to assess the adequacy of and the reporting of IOCs during LC. Methods: IOCs obtained from 300 consecutive LCs between July 2014 and July 2016 were analysed retrospectively by two surgical trainees and confirmed by a radiologist. Biliary tree anatomy was classified from IOC films as described by Couinaud (1957) and correlated with documented findings. The accuracy of intraoperative reporting was assessed. Biliary anatomy was correlated to clinical outcome. Results: A total of 95% of IOCs adequately demonstrated biliary anatomy. Aberrant right sectoral ducts were identified in 15.2% of the complete IOCs, and 2.6% demonstrated left sectoral or confluence anomalies. Only 20.4% of these were reported intraoperatively. Bile leaks occurred in two patients who had IOCs (0.73%) and two who did not (7.4%). Conclusion: Surgeons generally demonstrate biliary anatomy well on IOC but reporting of sectoral duct variation can be improved. Further research is needed to determine whether anatomical variation is related to ductal injury. Introduction Injury to the biliary tree occurs in approximately 0.1–0.5% of cholecystectomies. 1–6 Biliary injury has enormous consequences in terms of mortality and potential long-term morbidity. This, in turn, is associated with substantial cost and a major impact on quality of life. 7–9 Bile duct injuries (BDIs) result from factors including poor heuristic awareness, anatomical variability and the pathology of the diseased gallbladder. Biliary anatomical anomalies are also impor- tant if subsequent hepatic resection is performed. 4 Anomalies of biliary anatomy are common, occurring in up to 40% 2,3 of the population. These variants have been classified by Couinaud, 1 Champetier, 10 Huang, 11 Yoshida, 12 Choi, 13 Ohkubo 14 and Karakas. 15 Accurate identification of these variants is a crucial factor in reducing the incidence and severity of biliary injuries. Potentially, they can be identified pre-operatively with magnetic resonance imaging or computed tomographic cholangiography, but these are expensive investigations and not routine in the Australian setting. There is ongoing debate as to whether routine intraoperative cholangiography (IOC) should be performed. 16,17 It is a cheap and effective way of identifying unsuspected stones in the common bile duct and delineates the biliary anatomy. Logically, correct identifi- cation of the biliary anatomy by the dissection of Calot’s triangle to achieve the critical view of safety (CVS) 18,19 and supplementing this with a good quality IOC should minimize the risk of inadvertent BDI. © 2019 Royal Australasian College of Surgeons ANZ J Surg (2019) ANZJSurg.com