Intraoperative Cholangiography Guidelines: Routine, Selective, or Never? — Behind The Knife: The Surgery Podcast

In this episode, we use the recent SAGES guidelines to tackle one of the most common and controversial questions in general surgery. Through a case-based discussion, our experts review the evidence for intraoperative biliary imaging, discuss strategies for difficult anatomy, and compare IOC with other imaging modalities. Join us as we translate the latest recommendations into practical lessons that can be applied in the operating room.

Take Home Points:

Routine IOC is supported; however, this remains a conditional recommendation that should be individualized based on anatomy, surgeon experience, and available resources.
Use a selective approach to IOC in special populations, including pediatric and pregnant patients, where risks and benefits may differ.
Alternative imaging modalities including ICG fluorescence and laparoscopic ultrasound have complementary roles.
Routine IOC may help maintain surgeon and team proficiency, and trainees should learn both IOC performance and interpretation

Hosts:

Jason Bingham, MD – General and Bariatric Surgeon
Nicole L. Petcka, MD, MHPE – General Surgery Resident at Emory University

Guests:

Emily Miraflor, MD – General and Colorectal Surgeon at UCSF East Bay, Senior Author on the SAGES Guidelines
Kevin El-Hayek, MD - HPB and Foregut Surgeon at MetroHealth and Professor of Surgery at Case Western Reserve School of Medicine, Chair of the SAGES HPB/Solid Organ Committee
Dena Shehata, MD - SAGES Guideline Fellow, Co-first author on the SAGES Guidelines

Resources:
Kumar, S. K., Shehata, D. G., Cetrulo, L. N., Ignacio, R., Chiu, J., Davis, B. R., McDonald, M., Bloom, M. B., Ayloo, S., Kchaou, A., Orthopoulos, G., Pucher, P. H., Oliphant, U., Hallowell, P. T., Serrot, F., Overby, D., Moreno-Paquentin, E., Slater, B. J., & Miraflor, E. (2025). SAGES guidelines for the use of intraoperative imaging of the common bile duct. Surgical endoscopy, 39(11), 7091–7102. https://doi.org/10.1007/s00464-025-12142-0

SAGES Safe Cholecystectomy Program -
https://www.sages.org/safe-cholecystectomy-program/