Intraoperative cholangiography (IOC), described by Mirizzi in 1932, represented a significant advance in the diagnosis of choledocolithiasis during cholecystectomy. The natural history of asymptomatic choledocolithiasis has been investigated in different populations and its therapeutic management continues to be controversial. IOC is traditionally advocated as a procedure to be adopted in all laparoscopic cholecystectomies since it permits to define the anatomy of the biliary tract and to detect common bile duct stones. However, in the laparoscopic era, technological advances in radiologic-endoscopic workup have markedly increased the costs of investigation of patients with suspected choledocolithiasis. The routine use of IOC has raised the question of which cases require the exploration of bile tract anatomy during surgery and whether there are methods to predict preoperatively unsuspected choledocolithiasis. Therefore, the most appropriate management of preoperatively unsuspected choledocolithiasis, i.e., the routine or selective use of IOC, still remains undefined. In this respect, well-defined criteria for the inclusion of patients with possible choledocolithiasis who should be submitted to cholangiography exist in the literature, but there is no safe approach to exclude asymptomatic patients without an indication for contrast examination.

A systematic literature search was performed by KOVACS N, et al (2022) using the following search keys: cholangiogra* and cholecystectomy. The primary outcomes were BDI and retained stone rate. To investigate the differences between the groups (routine IOC vs selective IOC and IOC vs no IOC), they calculated weighted mean differences (WMD) for continuous outcomes and relative risks (RR) for dichotomous outcomes, with 95% confidence intervals (CI). Of the 19,863 articles, 38 were selected and 32 were included in the quantitative synthesis. Routine IOC showed no superiority compared to selective IOC in decreasing BDI (RR = 0.91, 95% CI 0.66; 1.24). Comparing IOC and no IOC, no statistically significant differences were found in the case of BDI, retained stone rate, readmission rate, and length of hospital stay. They found an increased risk of conversion rate to open surgery in the no IOC group (RR = 0.64, CI 0.51; 0.78). The operation time was significantly longer in the IOC group compared to the no IOC group (WMD = 11.25 min, 95% CI 6.57; 15.93). So this data findings suggest that IOC may not be indicated in every case, however, the evidence is very uncertain.