INTRAOPERATIVE CHOLANGIOGRAPHY AND ANTEROGRADE COMMON BILE-DUCT EXPLORATION IN LAPAROSCOPIC CHOLECYSTECTOMY - TECHNIQUE, RESULTS, PERSPECTIVES

The avoidance of (unrecognized) bile duct injuries (1) and the management of bile duct stones (pre-, intra- or postoperatively?) (2) are believed to be the main problems in laparoscopic cholecystectomy (LCE) at present. They must be a challenge for surgery to develop and improve the concepts of minimally invasive therapy for treatment of cholelithiasis. Intraoperative cholangiography (IOC) plays a very important role and is the basis of innovative, laparoscopically assisted procedures (3) for single session therapy of gallbladder and bile duct stones. (1) A detailed analysis of the literature proves the value of IOC for avoidance or early recognition of iatrogenic bile duct injuries. IOC is of most importance to compensate fundamental restrictions of the laparoscopic technique (missing possibility for palpation or anterograde preparation). IOC adds additional safety to the laparoscopic procedure and detects unsuspected bile duct stones. (2) At present, surgical management of cholecysto-/choledocholithiasis is splitted in two independent procedures: LCE and pre- or postoperative endoscopic retrograde cholangiography (ERC) with optional endoscopic papillotomy (EPT). A critical analysis of the literature and of the results of 623 LCE performed between 10/91 and 9/93 in the own institution leads to the following conclusions: Preoperative ERCs are performed unnecessary in about 50% of cases. They could be avoided by routine use of IOC. The combination of two independent procedures (LCE and ERC/PT) for treatment of cholelithiasis increases mortality and morbidity. Thus, the outcome of therapeutic splitting'' is not clearly superior to conventional treatment by open surgery. The inconvenience for our patients caused by the operation itself and one or more additional endoscopic procedures disagrees with the principles of minimally invasive therapy and raises the overall costs and the duration of treatment. (3) The transcystic anterograde access to common bile duct exploration (CBDE) is recommended as an alternative for the concept of ,,therapeutic splitting''. If CBD-stones are suspected or present, IOC with optional transcystic common bile duct exploration allows final diagnosis and treatment in a single session. Additional risks and costs caused by choledochotomy as well as by pre- or postoperative endoscopic retrograde procedures (ERC, EFT) are avoided. Techniques and equipment of IOC and transcystic common bile duct exploration are presented in detail. Of 22 transcystic common bile duct explorations 20 were performed without complications. Two cases required conversion to open surgery. The use of pulsed dye laser or electro-hydraulic lithotripsy under direct endoscopic control is recommended for treatment of large and impacted stones. Randomized studies for further evaluation of the different therapeutic modalities are urgently required.