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Minimally invasive surgery has revolutionized the way we perform surgery due to the benefits of enhanced recovery, specifically less postoperative pain and fewer wound-related complications. These surgical techniques have become widespread and the gold standard for the management of certain entities as a result of outcomes data, improved equipment (including smaller, user-friendly articulating instruments and robotic-assisted surgery), patient expectations, and the easily accessible worldwide media.

The advanced minimally invasive surgical techniques in this chapter address the role of intraoperative imaging and the management of bile tract stones, tumors, and cysts. These approaches are ideally offered in an environment where a multidisciplinary approach is provided. As the demand for less invasive and more subspecialized expertise increases, knowledge of how this field is evolving will be important in offering our patients the best clinical care with the least associated procedural risk.


Clarifying biliary anatomy to facilitate safe surgical dissection or identifying biliary ductal injuries is essential. A meticulous dissection of the gallbladder with the “critical view of safety” approach has been used for this purpose.1 When this technique or other surgical approaches do not provide this information or when they cannot be performed safely, the use of intraoperative imaging such as intraoperative cholangiogram (IOC) is required. Additional indications for the use of IOC include the presence of jaundice, elevated liver function or pancreatic enzymes levels, biliary ductal dilation, or stones on imaging. A meta-analysis revealed that the incidence of unsuspected retained stones after a cholecystectomy was 4%, with only 15% of these going on to cause clinical problems.2 The probability of this pathology can be classified as low (<5%), medium (5%-50%), and high (>50%) according to bilirubin level (<1.8, 1.8-4, and >4 mg/dL), dilation of common bile duct (CBD; >6 mm), and clinical signs of cholangitis.3 Because small stones may pass spontaneously, a preoperative endoscopic retrograde cholangiography (ERC) is not necessary or efficient in most cases, and laparoscopic cholecystectomy with IOC will suffice to document a clear CBD during cholecystectomy; if needed, a postoperative ERC can be used for those with clinically significant residual stones.4-6 Using fluoroscopic IOC, stones can be identified with greater than 95% sensitivity and specificity, with a 5% false-positive rate and 1% false-negative rate, although these rates are highly variable depending on the study.7 Magnetic resonance cholangiography (MRC) has a high sensitivity (90%) and specificity (95%) for choledocholithiasis with a low-risk profile compared to ERC and thus occupies a place in the management algorithm when there is medium probability.8 If stones are encountered during MRC, then proceeding with preoperative ERC is recommended. If stones are not diagnosed on MRC, proceeding with a laparoscopic cholecystectomy with IOC is recommended. A proposed algorithm to address clinically suspected CBD stone is presented (Fig. 66-1).

Figure 66-1

Preoperative management algorithm for suspected clinically relevant common bile duct stones. CBD, common ...

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