Currently, various methods for administering contrast agents under laparoscopic guidance have been developed and introduced into clinical practice: transvesical cholecystocholangiography, laparoscopic transhepatic cholecystocholangiography, and laparoscopic hepatocholangiography. These techniques are successful in most cases; they are informative and relatively safe. Indications and contraindications: Elective laparoscopic cholangiography (LCH) is indicated for chronic and malignant diseases of the hepatopancreatoduodenal organs, the diagnosis of which has not been established by other methods and it is impossible to determine the treatment strategy for patients or plan the scope of surgical interventions. Emergency LCH is indicated in cases where the type of jaundice (mechanical or parenchymal) is unclear during laparoscopy, cholestatic jaundice is suspected, and a combination of benign and malignant lesions of the biliary system must be excluded. The choice of laparoscopic cholangiography method—transhepatic cholecystocholangiography (THC) or hepatocholangiography (HCH)—is based on a thorough examination of the liver, gallbladder, hepatoduodenal ligament, and other parts of the hepatopancreatoduodenal region, determining the anatomical changes, and, in the case of jaundice, the level of bile duct obstruction. THC is indicated for occlusions above the confluence of the cystic and common hepatic ducts; both techniques can be performed below this level; however, they are contraindicated in the presence of multiple primary and metastatic malignant liver tumors. Contraindications to THC include massive adhesions obstructing the gallbladder; collapsed gallbladder; hydrops and empyema of the gallbladder. Equipment. THC primarily requires X-ray equipment and radiocontrast agents. For successful and safe duct puncture and LHG, thin needles (0.5-0.7 mm in diameter) with a stylet are required. Long stylets with flexible ends and catheters (2-2.5 mm in diameter and 250 mm in length) are used for subsequent drainage of the intrahepatic ducts. A Seldinger-type technique is used for duct puncture, using the following instruments: a needle, a thin trocar, an adapter, and a catheter with an outer diameter of 2-2.5 mm and a length of 250 mm. Transhepatic puncture and subsequent gallbladder drainage can be performed using curved trocars up to 5 mm in diameter, through which a drainage catheter is inserted into the gallbladder. The end of the catheter left in the gallbladder and ducts should be curved: it straightens on the stylet, and upon removal, the stylet assumes a curved position and is fixed in the bile ducts. Technique. LCG is performed through anterior approaches with the patient in a supine or oblique position on the left side (Fig. 1). These approaches are somewhat inconvenient for duct puncture through lateral approaches. In cases of cholangitis, thick bile, and bile duct hypertension, these positions hinder the diffusion of contrast medium into the distal biliary tract, and cholangiograms are always performed with the patient standing. Gallbladder puncture is performed through the liver and directly through the gallbladder wall at the mucosal fold, fundus, and body. The first approach is preferred as safer. The puncture site of the anterior abdominal wall is selected under laparoscopic guidance in the right upper quadrant of the abdomen. The needle and trocar are passed through the liver tissue, leaving a 1-4 cm margin from the edge. If the gallbladder is enlarged and distended, it is difficult to determine the transition zone, and the liver puncture site and its bed may be selected incorrectly (close to the edge). This error results in a direct rather than transhepatic gallbladder puncture, which indicates a real risk of bile leakage into the abdominal cavity. After the puncture, the gallbladder contents are aspirated and their nature is assessed. Dark green bile is typical of early jaundice with low protein levels, light bile is typical of gallbladder hydrops and long-term obstructive jaundice, and purulent bile is typical of phlegmonous cholecystitis and gallbladder empyema. Anterior and lateral approaches are most often used for puncture of the intrahepatic bile ducts. With anterior approaches, to puncture the right lobe, the needle is inserted along the midclavicular line at the costal margin, 2-4 cm lateral and inferior to the xiphoid process, and to puncture the left lobe, it is inserted directly beneath it. With the lateral approach, the needle is inserted in the eighth to tenth intercostal space along the anterior and midaxillary lines. With the anterior approach, the needle is inserted at a 45° angle superiorly and posteriorly. With the lateral approach, the needle is inserted forward and medially at a 30° angle along the anterior axillary line, and at a 90° angle along the midaxillary line. The needle is inserted into the liver parenchyma to a depth of 10-12 cm during apnea. The direction and depth of needle insertion are best controlled radiographically, focusing on the 11th-12th thoracic vertebrae, the projection of whose transverse processes it should reach. After removing the mandrin, the needle is slowly withdrawn. The position of the needle tip in the duct, vessel, and liver parenchyma is monitored by the nature of the discharge and by the introduction of a contrast agent under fluoroscopic control. Bile, clear fluid (white bile in prolonged jaundice), and blood may be discharged from the needle. The appearance of blood indicates that the needle tip is located in one of the intrahepatic vessels and the direction of needle advancement must be changed. The duct is easier to locate under fluoroscopic control: a small persistent depot of contrast medium on the screen indicates the location of the needle tip in the liver parenchyma; when in a vessel, the contrast medium quickly "blurs" and disappears; if the needle tip is in the bile duct, its shadow is visible on the screen. In case of failure, the puncture can be attempted 4-5 times, changing the direction of needle insertion, but without completely removing it from the liver: new trauma increases the risk of bleeding and bile leakage. After a successful duct puncture, cholangiography is performed either immediately, by injecting a contrast medium through the needle, or after draining the bile ducts with a catheter. Control studies are performed after 2-4 days. The main rules for performing LCG and preventing diagnostic errors are: 1) using low concentrations of radiocontrast agents at the beginning of the study; 2) preliminary decompression of the biliary system by aspiration of thick and purulent bile; 3) visual monitoring of the distribution of the contrast agent through the biliary tract; 4) obtaining radiographs at different stages of the examination and in different patient positions, and in cases of gallbladder and bile duct drainage, immediately afterwards rather than several days later; 5) slow (over the course of 24 hours) removal of the drainage from the bile ducts under the control of abdominal drainage. The examination is completed by removing the needle and catheter, draining the biliary tract, visual monitoring of the liver puncture site, leaving a control drainage in the subhepatic space, and studying the dynamics of the passage of the contrast agent into the duodenum. The team for performing LCG should consist of at least 3 members: one physician's assistant - a surgical nurse, the other - participates in stages of the operation that do not require sterile conditions. Failures, dangers and complications. LCG failures include: the gallbladder is not visible due to adhesions with surrounding organs and the greater omentum; puncture of the gallbladder and intrahepatic bile ducts is unsuccessful due to the anatomical structure and morphological changes of the liver and gallbladder; the radiopaque agent fills only part, not all, of the hepatic bile ducts; and the examination is terminated due to complications. Failures, which reach 20-30%, may include insufficient experience of the performer, poor technical equipment, and topographic and anatomical features and morphological changes of the liver and gallbladder. Complications are general and local. General complications include deterioration of the cardiovascular and respiratory systems, while local complications include liver injury and injuries to other organs of the abdominal and thoracic cavities. The risk of bleeding and bile leakage from the liver puncture site is particularly high in patients with jaundice and is explained by hypertension in the bile ducts, changes in the liver parenchyma, impaired coagulation, and other causes. To stop bleeding and bile leakage after liver puncture, electrocoagulation, sealing of the puncture channels with rapidly hardening substances, and tamponade with catheters are used. Coagulation should be performed over most of the puncture channel, not just the puncture site, as the scab that forms on the liver surface is poorly adherent and is rejected by the pressure of leaking blood and bile.