Videoconferencing for multidisciplinary evaluation in single-session cholecystectomy and ERCP

Single-session laparoscopic cholecystectomy preceding ERCP for positive intraoperative cholangiography (IOC) is safe, effective, and economic, and it reduces hospital stay compared with a dual-session procedure. The typical protocol is suboptimal, involving either independent clinical interpretation by the surgeon or the presence of the endoscopist at the time of fluoroscopic imaging. Videoconferencing is universal, compliant with the Health Insurance Portability and Accountability Act, and provides faithful quality, which, if used during IOC, facilitates multidisciplinary decisions despite an offsite endoscopist. Here we present a case involving a young woman found to have cholelithiasis on abdominal ultrasonography without extrahepatic biliary dilatation or stone. Her laboratory test results were unremarkable except for a mild elevation in total bilirubin over the 8-hour interval before elective laparoscopic cholecystectomy. Before the surgery, an IOC was planned with real-time videoconferencing to allow the off-site endoscopist to confer and provide expert opinion (Fig. 1A). After a complex 2-hour skeletonization, IOC was performed and shared by videoconferencing (Fig. 1B; Video 1, available online at www.giejournal.org). A clear convexity was found within the distal common duct without drainage to the small bowel, suggesting an obstructing stone (Fig. 1C), and the surgeon and endoscopist agreed that tandem ERCP was indicated, during which sphincterotomy was performed and the stone was removed (Fig. 1D).