420 A Novel Difficulty Grading System for Intraoperative Cholangiography in Laparoscopic Cholecystectomy

Abstract Introduction Intraoperative cholangiography (IOC), once the gold standard during open cholecystectomy, has become a controversial and inconsistently applied step in laparoscopic cholecystectomy (LC). Factors such as inadequate training, variable difficulty, and divergent surgical techniques might contribute to its declining use. Method We propose a novel IOC difficulty classification based on Mr. Nassar's standard IOC technique where 5 Fr (or 4 Fr for narrow ducts) ureteric catheter introduced from the medial right upper quadrant port, employing a trans-cystic basket-in-catheter (BIC) technique. Prospectively collected data and vidoes for LC operations performed by a single surgeon adopting index admission, single-session management of cholelithiasis from January 2023 to June 15, 2025. Classification Grade I: From the initial CD cut Grade II: Only possible by engaging the tip of the catheter and using the cholangiogram-clamp CD manipulation or proximal CD dissection is required Grade III: Proximal dissection of CD up to the junction between CD-common hepatic duct (CHD) junction Impacted proximal CD stone (Ghost stone) Grade IV: IOC only possible from the Gallbladder when CD access is not feasible. Grade V: only possible through Direct bile duct (BD) puncture. Subgrade “A”: when Guidewire assistance required. Results Grade I in 70%, Grade II in 18% (IIA 2%), Grade III in 6% (IIIA 2%), Grade IV in 2% (IVA 1%), whereases cholangiography was abandoned in 1% where BD puncture was not indicated. Conclusions This classification provides a structured approach to standardizing and assessing IOC difficulty in LC, potentially improving training and procedural consistency.