Laparoscopic cholecystectomy has become the standard of care for symptomatic cholelithiasis, acute and chronic cholecystitis, and biliary dyskinesia (defined as an ejection fraction < 35% on HIDA scan). There is a relatively low morbidity 1-9% with conversion to open rates of 1.8-7.8%. This procedure epitomizes the principles of laparoscopy as outlined earlier. The major complication seen with laparoscopic cholecystectomy is injury to the common bile duct (CBD), which occurs 0.2-0.7%. This is more frequent than with the open procedure. Techniques to reduce injuries to the CBD include use of a 30° scope with cephalic and lateral retraction of the gallbladder to expose the triangle of Calot. Other complications include hemorrhage, bile leaks, retained stones and pancreatitis.

Indications for intraoperative cholangiogram, include elevated liver function tests, dilated common bile duct, ambiguous anatomy, inability to clear the CBD by pre-operative ERCP, and the presence of multiple small stones. Intraoperative strategies for common bile duct stones:

• Stones < 3 mm-IV glucagon and rapid infusion of saline through cholangiocath into CBD.

• > 3 mm, or if CBD dilated-best removed through cystic duct with a stone basket.

• > 8 mm- choledochotomy, stone extraction and T-tube. Laparoscopic CBD exploration has been shown to be as effective and more cost-efficient as postop ERCP.

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