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Background: Intraoperative cholangiography (IOC) is a contrast-enhanced X-ray acquired during laparoscopic cholecystectomy. IOC images the biliary tree whereby filling defects, anatomical anomalies and duct injuries can be identified. In Australia, IOC are performed in over 81% of cholecystectomies compared with 20 to 30% internationally (Welfare AIoHa in Australian Atlas of Healthcare Variation, 2017). In this study, we aim to train artificial intelligence (AI) algorithms to interpret anatomy and recognise abnormalities in IOC images. This has potential utility in (a) intraoperative safety mechanisms to limit the risk of missed ductal injury or stone, (b) surgical training and coaching, and (c) auditing of cholangiogram quality., Methodology: Semantic segmentation masks were applied to a dataset of 1000 cholangiograms with 10 classes. Classes corresponded to anatomy, filling defects and the cholangiogram catheter instrument. Segmentation masks were applied by a surgical trainee and reviewed by a radiologist. Two convolutional neural networks (CNNs), DeeplabV3+ and U-Net, were trained and validated using 900 (90%) labelled frames. Testing was conducted on 100 (10%) hold-out frames. CNN generated segmentation class masks were compared with ground truth segmentation masks to evaluate performance according to a pixel-wise comparison., Results: The trained CNNs recognised all classes.. U-Net and DeeplabV3+ achieved a mean F1 of 0.64 and 0.70 respectively in class segmentation, excluding the background class. The presence of individual classes was correctly recognised in over 80% of cases. Given the limited local dataset, these results provide proof of concept in the development of an accurate and clinically useful tool to aid in the interpretation and quality control of intraoperative cholangiograms., Conclusion: Our results demonstrate that a CNN can be trained to identify anatomical structures in IOC images. Future performance can be improved with the use of larger, more diverse training datasets. Implementation of this technology may provide cholangiogram quality control and improve intraoperative detection of ductal injuries or ductal injuries., (© 2024. The Author(s).)

Background: Ideal visualization of fluorescent cholangiography during laparoscopic cholecystectomy is when maximum fluorescence into biliary ducts and absent signal into liver parenchyma, defined as "signal to background ratio" (SBR), is obtained. Such condition is mainly dependent by indocyanine green (ICG) dose and timing. The aim of this study was to identify the ideal ICG dose to obtain the best possible intraoperative visualization of the extra-hepatic biliary tree., Methods: The first part of the study was used to define a range of small weight-based ICG dosages using the mathematical function bisection method. During the second part of the study, the midpoint dose of the identified range, was tested in 50 consecutive cholecystectomies using a laser-based fluorescence laparoscopic camera (Synergy ID system by Arthrex, Naples, FL, USA). Timing administration was set at 1 h before surgery, since this is the most common situation in clinical practice. Fluorescence intensity of bile ducts and liver parenchyma were assessed both subjectively, by blinded operative surgeon, as well as objectively, using an image analysis software (Fiji plugin), before and after Calot's triangle dissection., Results: Fourteen patients were included in the first part of the study and ICG dose between 0.01191406 and 0.0119873 mg/kg was identified. The second part confirmed previous results after testing the dosage equal to 0.0119 mg/kg (midpoint of the defined range) in 50 consecutive cholecystectomies. Cystic duct was identified in 66 and 100% of cases before and after dissection of Calot's triangle respectively. On the other hand, common bile duct was identified in 82 and 92% before and after dissection respectively. Subjective and objective SBRs confirmed the benefit of the identified ICG dose., Conclusion: ICG dose calculated by 0.0119 mg/kg administered one hour before surgery allows an ideal intraoperative visualization of the extra-hepatic biliary tree., Registration Number: ISRCTN10190039., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Most bile duct (BDI) injuries during laparoscopic cholecystectomy (LC) occur due to visual misperception leading to the misinterpretation of anatomy. Deep learning (DL) models for surgical video analysis could, therefore, support visual tasks such as identifying critical view of safety (CVS). This study aims to develop a prediction model of CVS during LC. This aim is accomplished using a deep neural network integrated with a segmentation model that is capable of highlighting hepatocytic anatomy., Methods: Still images from LC videos were annotated with four hepatocystic landmarks of anatomy segmentation. A deep autoencoder neural network with U-Net to investigate accurate medical image segmentation was trained and tested using fivefold cross-validation. Accuracy, Loss, Intersection over Union (IoU), Precision, Recall, and Hausdorff Distance were computed to evaluate the model performance versus the annotated ground truth., Results: A total of 1550 images from 200 LC videos were annotated. Mean IoU for segmentation was 74.65%. The proposed approach performed well for automatic hepatocytic landmarks identification with 92% accuracy and 93.9% precision and can segment challenging cases., Conclusion: DL, can potentially provide an intraoperative model for surgical video analysis and can be trained to guide surgeons toward reliable hepatocytic anatomy segmentation and produce selective video documentation of this safety step of LC., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Post-cholecystectomy transected bile ducts (TBDs) are not amenable to standard endoscopic management. Combined ERCP and endosonography (CERES) including EUS-guided hepaticoenterostomy enhance therapeutic biliary endoscopy. CERES treatment of post-cholecystectomy TBDs is evaluated., Methods: Among 165 consecutive patients who underwent ERCP for post-cholecystectomy bile duct injury (Amsterdam A/B/C/D grades [%] = 47/30/7/16) between January 2009-November 2020 at a tertiary-care center, 10/26 (38%) with TBDs (6 female; 32-92 years old) underwent CERES before attempted endoscopic repair (staged CERES, n = 7) or surgical repair (preoperative CERES, n = 1), or as destination therapy (definitive CERES, n = 2). Short-term clinical success rate, final clinical success rate and comprehensive complication index (CCI) were retrospectively determined. Additionally, number of follow-up procedures, adverse events, recurrences, final patency grades and definitive cure rate were determined in patients with staged CERES., Results: Index CERES (hepaticogastrostomy, 60%; hepaticoduodenostomy, 40%) achieved bile leak and jaundice resolution in 10 patients (100% short-term clinical success rate). Overall, 9/10 patients maintained good/excellent biliary drainage over a median 3.2 years without any unplanned percutaneous/surgical procedures (90% final clinical success rate; median CCI = 8.7). Staged CERES using recanalization (n = 6) or diversion (n = 1) strategies achieved Grade A patency in 5/7 (71%) patients after a median of 2 follow-up procedures over a median 12-month treatment period; 2 failed recanalization patients were salvaged by indefinite hepaticoenterostomy stent or elective surgery, respectively. Among staged CERES, 2 treatment-related cholangitis occurred (29%) and 2 recurring strictures (29%) developed over a median 8.4 year follow-up; recurring strictures were endoscopically remodeled (n = 1) or indefinitely stented (n = 1); final Grade A/B biliary patency was achieved in 5/7 (71%) and definitive cure in 4/7 (57%)., Conclusions: CERES controls acute symptoms in selected post-cholecystectomy TBD patients allowing subsequent staged endoscopic therapy. Definitive cure or long-term biliary drainage is possible in most cases and elective surgery can be facilitated in the remainder., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Despite extensive preoperative evaluation, a significant proportion of patients with biliary cancer (BC) proves to be unresectable at laparotomy. Diagnostic laparoscopy (DL) has been suggested to avoid unnecessary laparotomy. Aim of the study was to evaluate the additional benefit of combining LUS to DL in patients with proximal BC., Methods: Inclusion criteria were all patients affected by proximal BC undergone DL + LUS based on the following criteria: preoperative diagnosis of gallbladder cancer, hilar cholangiocarcinomas (HC) and borderline resectable intrahepatic cholangiocarcinoma (IHC). The overall yield (OY) and accuracy (AC) of DL ± LUS in determining unresectable disease were calculated., Results: From 01/2006 to 12/2014, 107 out of 191 (56%) potentially resectable proximal BC were evaluated. One hundred patients fulfilled inclusion criteria: 44 IHC, 21 GC and 35 HC. Forty-eight (48%) patients were male with median age of 65 (41-87) years. The median number of preoperative imaging was 3 ± 0.99. Patients underwent DL + LUS 10.5 ± 15.6 days after last imaging. DL + LUS identified unresectable diseases in 24 patients, 6 (25%) of them only thanks to LUS findings (3 GC and 3 IHC). At laparotomy, 6 (4 HC and 2 GC) out of 76 patients were found unresectable because of carcinomatosis (n = 2), new liver metastasis (n = 2) and vascular invasion (n = 2). LUS increased the OY (from 18 to 24%) and AC (from 60 to 80%) in the whole group. The advantages of LUS were confirmed for GC (OY from 38.1 to 52.4%, AC from 61.5 to 84.6%) and IHC patients (OY from 11.4 to 18.2%, AC from 62.5 to 100%) but not for HC group. The presence of biliary drainage was the only factor able to predict negative yield (p < 0.001)., Conclusions: LUS increases overall yield and accuracy of DL for detecting unresectable disease in patients with preoperative diagnosis of gallbladder cancer and borderline resectable intrahepatic cholangiocarcinomas.

Background: Intraoperative fluorocholangiography (IOC) has been the standard method for bile duct imaging during cholecystectomy. Laparoscopic ultrasound (LUS) has been evaluated as a possible alternative, but has been used less frequently. The authors examined the evolving use of these two methods to assess the relative utility of LUS as the primary method for routine bile duct imaging during laparoscopic cholecystectomy (LC)., Methods: This study analyzed a prospective database containing 423 consecutive cholecystectomies performed by one attending surgeon in an academic medical center between 1995 and 2005., Results: Intraoperative bile duct imaging was performed in 371 (94%) of 396 LCs performed for cholelithiasis. As recorded, IOC was performed in 239 cases, LUS in 236 cases, and both in 104 cases. Choledocholithiasis was present in 50 patients (13%). Common bile duct stones (CBDS) were identified by LUS in 3% of the patients without preoperative indicators of CBDS, and in 10% of the patients with one or more indicators. As shown by the findings, LUS had a positive predictive value of 100%, a negative predictive value of 99.6%, a sensitivity of 92.3%, and a specificity of 100% for detecting CBDS. Also, LUS identified clinically significant bile duct anatomy in 6% of the patients. In 1995, LUS was used for 20% of cases, whereas by 2005, it was used for 97% of cases. Conversely, the use of IOC decreased from 93% to 23%., Conclusions: With moderate experience, LUS can become the primary routine imaging method for evaluating the bile duct during LC. It is as reliable as IOC for detecting choledocholithiasis. In addition, LUS can locate the common bile duct during difficult dissections. On the basis of this experience, LUS is used currently in nearly all LCs and is the sole method for bile duct imaging in 75% of these cases. IOC is used as an adjunct to LUS when LUS imaging is inadequate, when stronger clinical indicators of choledocholithiasis are present, or when biliary anatomy remains uncertain.

Background: One complication of radiofrequency ablation (RFA) of the liver is biliary duct damage. Intraductal cooling (IDC) has been proposed as a means of protection., Methods: In the first experiment, designed to evaluate the influence of IDC on the RFA procedure per se and on lesion formation, lesions were created in vivo in pig liver with and without IDC. The RFA needle was placed with a 1.5-cm safety margin from the bile ducts. In the second experiment, designed to evaluate the potential protective effects of IDC, lesions were created close to a bile duct with and without IDC., Results: With the safety margin, the RFA parameters and lesion size were not negatively affected by IDC. Microscopic examination revealed that IDC had a protective effect in most of the lesions created close to a bile duct., Conclusions: The IDC procedure was feasible and had no negative effect on the RFA procedure or the lesions. However, the protective effect of IDC was not statistically significant (p = 0.12).

Background: Anomalous insertion of the right hepatic duct into the cystic duct is a rare anatomic variation. At this writing, only nine cases have been reported in the literature. In the patients presenting with this anomaly, the surgeon may accidentally transect the right hepatic duct during cholecystectomy., Methods: We encountered a case of anomalous insertion of the right hepatic duct into the cystic duct, which was clearly demonstrated in the intraoperative cholangiography during laparoscopic cholecystectomy., Results: As the half-cut point of the cystic duct happened to be on the gallbladder side of the cystic duct, cholecystectomy was accomplished laparoscopically., Conclusions: In anomalous insertion of the right hepatic duct into the cystic duct, hepatic duct transection could happen. Preoperative precise evaluation of the biliary duct, awareness of potential biliary variations, and identification of all anatomic structures before ligation and division were essential to prevent bile duct injury.

We compared laparoscopic ultrasonography (LICU) with static (S) or dynamic (D) cholangiography (IOC) for assessment of duct anatomy an calculi in 209 patients. LICU visualized ducts in 88% compared with 93% for IOC (P = 0.046). Nineteen patients (9%) had stones: 17 were found by LICU (89%) and 10 (53%) by IOC (P = 0.032). Time to perform LICU (7 +/- 3 min) was less than IOC (13 +/- 6 min) (P < 0.0001). Time to perform SIOC (12 +/- 5 min) and DIOC (14 +/- 6 min) did not differ (P = 0.48), nor did these tests differ in accuracy. LICU provided useful anatomical information but IOC better defined anatomic anomalies. LICU required less time but was less reliable at defining anatomy and complete duct visualization. LICU was more sensitive for stones. SIOC and DIOC did not differ objectively. LICU and IOC are complementary.

Laparoscopic sonography was introduced at our institution in April 1991. It is presently being tested as an alternative to peroperative cholangiography as far as the visualization of the structures of the hepatoduodenal ligament--particularly the extrahepatic bile ducts--during laparoscopic cholecystectomy are concerned. So far, 75 patients have been examined with both modalities. The structures of the hepatoduodenal ligament could be seen sonographically in all patients, while in five patients, the cholangiography had to be aborted for technical reasons. Eleven patients (15%) had anatomical variations of the bile ducts. Nine of these were diagnosed sonographically. A duodenal diverticulum and a long common channel of common bile duct and pancreatic duct were seen only on cholangiography. Variations of the hepatic arteries were found in 15 patients (20%). We conclude that intraoperative laparoscopic sonography is a reliable tool for the visualization of the structures of the hepatoduodenal ligament. This new technique might replace peroperative cholangiography in the future.

Intracorporeal ultrasonography was used as a new method to examine the bile ducts during laparoscopic cholecystectomy. A prototype rigid 7.5-MHz ultrasound probe, 10 mm in diameter and 50 cm in length, was introduced during 25 laparoscopic cholecystectomies. A dual scanning technique was developed for complete examination of the bile duct. This entailed transverse scanning via the subxyphoid trocar and longitudinal scanning via the umbilical trocar. The intrahepatic ducts were also visualized by placing the probe on the liver surface. Color Doppler imaging was useful to quickly distinguish the duct from vascular structures. Laparoscopic ultrasonography clearly delineated the bile ducts in all operations except one. The time required for imaging was significantly shorter for ultrasonography than for cholangiography. Our preliminary experience demonstrates that a complete examination of the bile ducts can be performed with intracorporeal ultrasonography in a relatively short period of time.

The value of intraoperative echo-contrast ultrasound (US) as compared with plain US was studied in 19 patients presenting with malignant liver tumors. The contrast medium SHU 454 was intraoperatively injected via the portal venous system or the biliary tract. Using intraoperative echo-contrast US, extremely small liver tumors could be sought in a limited area of the liver. In comparison with plain US, the former technique resulted in better demarcation of especially small tumors, which were seen as echo-poor areas in relation to the surrounding liver tissue.

Miniaturization of ultrasound probes has made possible endoluminal investigation of small duct systems. We have used a 360 degree transaxial real-time sector-scan imaging system with a field of view of 3-5 cm. It operates at ultra-high frequencies, which allows very high resolution. Ten jaundiced patients, aged 35-73 years, were investigated. Malignant bile-duct obstructive disease was present in eight and benign strictures in the remaining two. In all of them the intrahepatic bile ducts had undergone percutaneous transhepatic cannulation for diagnostic and therapeutic purposes. The resolution capacity has been sufficient to allow studies of the bile duct wall and adjacent tissues, and it has thus been possible to study the papilla of Vater, biliary-enteric anastomoses, and adjoining portions of the pancreatic and cystic ducts. Adjacent vessels have been identified. This preliminary study indicates that the character of strictures and the extent of tumour growth may be evaluated, thereby demonstrating the clinical potential of these miniature transducers. Endoluminal ultrasound evaluation of the bile ducts may also be possible intraoperatively and as a supplement to duodenoscopy.