EXPLORATIONS OF THE COMMON BILE-DUCT IN THE ERA OF LAPAROSCOPIC SURGERY

The advent of laparoscopic surgical procedures has infatuated both patients and surgeons. Potential beneficiaries in France could number 50,000 per year for gall stone surgery alone. The affect this type of procedure could have on exploration of the common bile duct has led to a certain degree of controversy in the literature. From 10 to 15% of the patients who undergo cholecystectomy have a stone in the common duct and require specific treatment, The clinician thus must propose an exploration of the common duct and decide on whether it should be performed before, during or after cholecystectomy. The choice of the exploration technique is directly related to the planned surgical approach. Most surgeons have abandoned the dogma of systematic per-operative cholangiography. The risk of missing a stone in the common bile duct in patients with no suggestive clinical or laboratory signs has been evaluated at 0 to 2%, suggesting that per-operative exploration is needed only in symptomatic cases, Transcutaneous echography cannot be considered as the reference technique since its sensitivity in no greater than 80%, similar to intravenous cholangiography. Reliable exploration currently relies on two techniques: endoscopic retrograde cholangiography which gives the diagnosis in 95% of the cases and echoendoscopy which has the advantage of a lower rate of complications. Other new improvements including miniaturization of the endoscopes are currently being tested. The correct approach must take into account the planned surgical procedure, the age and clinical situation of the patient and the experience of the operators with each technique.