Choledochoscopy and operative fluorocholangiography in the prevention of retained bile duct stones

Choledochoscopy has become a clinically accepted adjunct to choledochotomy as a result of recent advances in optics and instrumentation technology. Experience with this diagnostic modality during the past 18 years has led to the development of a compact, right‐angled, rigid, rod‐lens choledochoscope. Because of the excellent image quality and easy manipulation of this new instrument, choledochoscopy can be easily incorporated into routine surgical procedures on the biliary tract. Clinical results of choledochoscopy in a recent series of 120 consecutive choledochotomies are presented. The incidence of retained stones was reduced to 2%. Further advantages were: direct endoscopic removal of calculi, biopsy of biliary tumors, and immediate interpretation of questionable operative cholangiograms. Direct visual diagnosis of the problematic distal duct facilitated appropriate operative management without prolonging operating time. The procedure was carried out without increasing the complication rate beyond that of standard choledochotomy. The standard technique of operative cholangiography, using a portable x‐ray machine, has many disadvantages, including extended operating time, blind exposure of the films, a high incidence of blurred or technically inadequate films, and frequent need to repeat the procedure. A technique of operative fluorocholangiography is described which uses fixed equipment that incorporates modern advances in diagnostic radiology, but is modified to suit the surgical environment. The contrast material inflow is observed by television‐fluoroscopy and the exposures, using indirect radiographic techniques, are made under visual control. The advantages of this new technique are: aimed small format film technique, automatic exposure (brightness, contrast) control, serial films (6–12 instead of 3), reduction of radiation, high quality films, and a significant decrease of time required for a complete examination (5 min). The value of operative fluorocholangiography is emphasized for assessment of sphincter function and duct motility, as well as for the localization of bile duct stones. Résumé Au cours des 18 dernières années, les progrès de l'optique et de l'instrumentation ont permis de construire un cholédocoscope compact, rigide, à angle droit, à fibres de verre. La cholédocoscopie est devenue un complément utile de la cholédocotomie. L'image étant excellente et la manipulation facile, l'instrument peut être utilisé en routine au cours de l'op