Imaging Evolution in Biliary Surgery

Abstract

Hepatobiliary-pancreatic (HBP) surgery has evolved from a high-risk discipline to a safe and precise specialty, due to the integration of imaging techniques.

Initially, in the pre-imaging era—before 1895—only clinical symptoms guided surgical decisions, making biliary interventions rare and dangerous procedures. The turning point was the discovery of X-rays, which allowed the first detection of gallstones in 1900.

A crucial breakthrough was intraoperative cholangiography (IOC), developed in 1932, which allowed intraoperative visualization of the biliary tree, greatly improving safety and accuracy. Fluoroscopy, only recently emerging as an innovative alternative that increases anatomical precision in real time and could reduce the use of IOC.

Ultrasound also became very important for differentiating structures, and Computed Tomography (CT) revolutionized medicine with detailed images that facilitate multidisciplinary approach . Magnetic resonance cholangiography (MRC) incorporated noninvasive diagnosis of the biliary tree through 3D images ideal for surgical planning.

Direct vision techniques, such as Endoscopic Retrograde cholangiopancreatography (ERCP), transformed treatment by integrating therapeutic procedures and reducing the need for open surgery. Endoscopic ultrasound has become essential for diagnosing pancreatic tumors.

Despite these advances, challenges such as high costs and lack of accessibility persist. The future of HPB surgery, with the integration of Artificial Intelligence and augmented reality, offers unprecedented diagnostic accuracy and therapeutic safety; beyond the debate on ethical aspects linked to digital diagnostic imaging, its margin of error, and the subsequent responsibility for therapeutic decision-making. In short, the human hand still governs biliary surgery, despite the development of imaging, which has been an essential tool for achieving precision and patient safety.