Table 1. Characteristics of the included studies.

CI, confidence interval; OR, odds ratio; $, US dollar; HR, hazard ratio

Authors	Year	Title	Study design	Summary of findings
Thacoor et al. [20]	2019	The role of intraoperative cholangiography in patients undergoing laparoscopic cholecystectomy for acute gallstone pancreatitis: is magnetic resonance cholangiopancreatography needed?	Retrospective study	Between October 1998 and December 2013, a total of 2,215 patients underwent laparoscopic cholecystectomy (LC). Ninety percent of patients with acute gallstone pancreatitis underwent laparoscopic cholecystectomy accompanied by intraoperative cholangiography (IOC). Intraoperative cholangiography revealed choledocholithiasis in 13 patients, of whom 11 received simultaneous treatment through trans-cystic duct exploration and clearance, and two patients necessitated postoperative endoscopic retrograde cholangiopancreatography (ERCP).
Reeves et al. [21]	2022	The price is right: Routine fluorescent cholangiography during laparoscopic cholecystectomy	Markov model decision analysis	The model's findings demonstrate that fluorescent cholangiography offers significant benefits over standard bright-light laparoscopic cholecystectomy, reducing lifetime costs by $1,235 per patient and enhancing effectiveness by 0.09 quality-adjusted life years (QALY) due to shorter operation durations (reduced by 21.20 minutes) and a lower open conversion rate (1.62% versus 6.70%). Probabilistic sensitivity analysis confirmed that in nearly 99% of model iterations, fluorescent cholangiography is more effective and less costly, even considering a willingness-to-pay threshold of $100,000 per quality-adjusted life year.
Esposito et al. [11]	2023	Systematic intraoperative cholangiography during elective laparoscopic cholecystectomy: Is it a justifiable practice?	Retrospective cohort study	Of 303 patients, 215 (71.0%) belonged to the IOC group, while 88 (29.0%) were in the non-IOC group. Incomplete or unclear IOC was found in 10.7% of cases, with a failure rate of 14.7%. The IOC group experienced a 15-minute longer operation time (P = 0.01) and exhibited higher postoperative complications (5.1% versus 0.0%, P = 0.03). All three cases of bile duct injuries (0.99%) were within the IOC group, one diagnosed intraoperatively and the other postoperatively. In terms of common bile duct (CBD) stone detection, IOC demonstrated 77% sensitivity, 98% specificity, 97.2% accuracy, a positive predictive value of 63%, and a negative predictive value of 99%.
Martin et al. [22]	2018	Selective intraoperative cholangiography during laparoscopic cholecystectomy in children is justified	Retrospective study	Intraoperative cholangiography found biliary abnormalities that required additional treatment in 6/62 (10%) of patients undergoing laparoscopic cholecystectomy. These findings support the use of intraoperative cholangiography in select individuals with CBD dilatation or preoperative imaging suspicion of ductal stones.
Rystedt et al. [23]	2021	Routine versus selective intraoperative cholangiography during cholecystectomy: systematic review, meta-analysis and health economic model analysis of iatrogenic bile duct injury	Systematic review and meta-analysis	Routine intraoperative cholangiography (IOC) detected 0.36% of bile duct injury, and selective IOC detected 0.53% of bile duct injury, significantly increasing the change of bile duct injury detection by selective IOC (OR, 1.43; 95% CI, 1.22-1.67). Through model analysis, it was projected that Sweden, with a population of 10 million, could avert seven injuries annually via routine IOC, consequently gaining 33 quality-adjusted life years (QALYs) over a decade. The associated net cost (€808,000) would amount to an approximate cost of €24,900 per QALY gained.
Lai et al. [24]	2022	Routine intraoperative cholangiography during laparoscopic cholecystectomy: application of the 2016 WSES guidelines for predicting choledocholithiasis	Retrospective study	A study included 990 patients who underwent laparoscopic cholecystectomy (LC) patients and routine intraoperative cholangiography (IOC). IOC revealed CBD stone in 19.9% of cases. Detection rates varied across low-, intermediate-, and high-risk groups. Predictors included the evidence of CBD stones on imaging, CBD diameter of >6 mm, total bilirubin of >4 mg/dL, abnormal liver tests, and clinical gallstone pancreatitis. The study identified major bile duct injuries in 0.4% of patients, all of whom successfully underwent repair surgery with uneventful recoveries.
Abdelaal et al. [2]	2017	Role of intraoperative cholangiography for detecting residual stones after biliary pancreatitis: still useful? A retrospective study	Retrospective study	In 84 out of 113 patients (74.3%), intraoperative cholangiography (IOC) revealed the presence of stones. A comparison between patients with and without stones found similar mean durations from hospital admission to surgery (5.9 days versus 6.1 days), from surgery to hospital discharge (2.0 days versus 2.2 days), and overall length of hospital stay (7.9 days versus 8.3 days) (P > 0.001).
Akingboye et al. [25]	2021	Outcomes From Routine Use of Intraoperative Cholangiogram in Laparoscopic Cholecystectomy: Factors Predicting Benefit From Selective Cholangiography	Systematic review and meta-analysis	Among 804 patients, 744 underwent intraoperative cholangiography (IOC). Filling defects were observed in 43 out of 744 patients (5.8%), with 23 out of the 43 cases undergoing stone extraction through endoscopic retrograde cholangiopancreatography (ERCP). Alkaline phosphatase (ALP) was a significant predictor of filling defects in IOC (OR, 1.003; 95% CI, 1.001-1.005; P = 0.015).
Ding et al. [12]	2015	Is intraoperative cholangiography necessary during laparoscopic cholecystectomy for cholelithiasis?	Prospective comparative study	The study included 371 participants aged 16-70, split into routine laparoscopic cholecystectomy (LC) (185) and LC + IOC (186) groups. Both groups were comparable in terms of demographics, gallstone attributes, and clinical symptoms. The rates of successful LC, CBD stone retainment, CBD injury, complications, and hospital stay duration showed no significant differences between groups. However, the LC + IOC group experienced a significantly longer mean operative time (52.86 ± 4.47 minutes versus 43.00 ± 4.15 minutes, P < 0.01). No fatal complications emerged, and a one-year follow-up identified minor digestive discomfort without abnormal radiological findings.
Tomaoğlu [26]	2020	Intraoperative Cholangiography in Laparoscopic Cholecystectomy: Technique and Changing Indications	Retrospective study	Of the 29 patients, 20 were females, and nine were males, with a mean age of 54.4 years. Successful IOC was achieved in 90% of cases, with a median duration of 21.9 minutes. Anatomical aberration was observed in one patient, wherein the cystic duct was connected to the right hepatic duct. The visualization of the Wirsung duct in another patient was due to the sphincter of Oddi hypertension. The procedure itself did not lead to any complications.
Silva et al. [27]	2013	Intraoperative cholangiography during elective laparoscopic cholecystectomy: selective or routine use?	Prospective study	Among the 243 patients, 33 (13.58%) were identified with choledocholithiasis. Of the 100 patients without an initial indication for this examination, only one case (1.0%) unveiled previously undetected choledocholithiasis. However, among the 143 patients with a preoperative indication for IOC, 32 (22.37%) cases of choledocholithiasis were observed.
Johansson et al. [28]	2021	Intervention versus surveillance in patients with common bile duct stones detected by intraoperative cholangiography: a population-based registry study	Retrospective study	The study included 134,419 patients who underwent cholecystectomy, with 2.0% undergoing ERCP for retained CBD stones. After accounting for factors such as cholecystectomy type, preoperative symptoms, age, and gender, the absence of IOC increased ERCP risk (HR, 1.4; 95% CI, 1.3-1.6). When CBD stones identified via IOC were managed through surveillance, the ERCP risk increased (HR, 5.5; 95% CI, 4.8-6.4). Even asymptomatic small stones (<4 mm) in the surveillance group had elevated ERCP risk compared to the intervention group (HR, 3.5; 95% CI, 2.4-5.1).
Iranmanesh et al. [29]	2018	Feasibility, benefit and risk of systematic intraoperative cholangiogram in patients undergoing emergency cholecystectomy	Retrospective study	Successful IOC was achieved in 509 out of 578 patients (88.1%). Primary factors influencing IOC failure were age, body mass index, male sex, and concurrent acute cholecystitis. Among patients with anticipated common bile duct stones during IOC, 32 underwent unnecessary negative postoperative assessments (6.3% of 509). A single adverse event related to IOC was recorded (mild pancreatitis, 0.2% of 578).
Askari et al. [13]	2021	Benefits of intraoperative cholangiogram for acute cholecystitis	Prospective study	Most (84.6%) patients underwent IOC. The overall complication rate was 8.1% (n = 55/676), notably lower in the IOC group (6.1%) compared to the non-IOC group (19.2%, P < 0.001). Specifically, there were reduced rates of retained stones (1.6% versus 3.8%, P < 0.001), bleeding (0.0% versus 2.9%, P < 0.001), and conversion to open surgery (0.7% versus 7.7%, P < 0.001). CBD injury rates (0.0% versus 0.3%, P = 0.5465) and bile leaks were comparable across groups (1.9% versus 0.9%). There was an association between IOC usage and lowered complication risk (OR, 0.27; 95% CI, 0.15-0.50; P < 0.001) and reduced conversion to open surgery (OR, 0.11; 95% CI, 0.03-0.37; P < 0.001).
Donnellan et al. [30]	2021	A meta-analysis of the use of intraoperative cholangiography; time to revisit our approach to cholecystectomy?	Meta-analysis	Routine intraoperative cholangiography led to the increased detection of bile duct stones during cholecystectomy compared to selective intraoperative cholangiography (OR, 3.28; 95% CI, 2.80-3.86; P < 0.001). Although bile duct injury incidence was slightly lower with intraoperative cholangiography (0.39%) than without (0.43%), the difference was not statistically significant (OR, 0.88; 95% CI, 0.65-1.19; P = 0.41). Readmission rates post cholecystectomy with intraoperative cholangiography were 3.0% and 3.5% without it (OR, 0.91; 95% CI, 0.78-1.06; P = 0.23).