Comparative validation of intraoperative ultrasound versus intraoperative cholangiography for the detection of choledocholithiasis

Intraoperative cholangiography (IOC) is widely used for biliary tract evaluation during laparoscopic cholecystectomy. Intraoperative ultrasound (IOUS), available for over two decades as a radiation-free alternative, remains underutilized. This study aimed to validate the diagnostic performance and clinical applicability of IOUS compared to IOC in identifying choledocholithiasis and delineating biliary anatomy. A prospective, single-center study included patients undergoing laparoscopic cholecystectomy with intermediate or high risk of choledocholithiasis according to the 2019 ASGE criteria. All patients underwent both IOUS and IOC. Diagnostic accuracy, procedure duration, and intraoperative findings were analyzed using IOC as the reference standard. Thirty patients were included. IOUS successfully visualized the biliary anatomy in 96.7% of cases. Ten patients (33.3%) had choledocholithiasis or biliary sludge. IOUS identified 9 of these cases, with a sensitivity 90.0% (95% CI 55.5–99.7) specificity 100.0% (95% CI 83.2–100.0) while IOC detected 7, sensitivity 70.0% (95% CI 34.8–93.3) specificity 100.0% (95% CI 83.2–100.0). The mean procedure time was significantly shorter for IOUS (5.6 min) than for IOC (12.5 min; p < 0.0001). No postoperative complications or readmissions occurred. IOUS demonstrated favorable diagnostic performance and shorter procedure times compared to IOC, suggesting that it may represent a reliable intraoperative imaging option in appropriately trained surgical teams.