T. Neufang et al., INTRAOPERATIVE CHOLANGIOGRAPHY AND ANTERO GRADE COMMON BILE-DUCT EXPLORATION IN LAPAROSCOPIC CHOLECYSTECTOMY - TECHNIQUE, RESULTS, PERSPECTIVES, Zentralblatt fur Chirurgie, 119(6), 1994, pp. 388-414
The avoidance of (unrecognized) bile duct injuries (1) and the managem
ent of bile duct stones (pre-, intra- or postoperatively?) (2) are bel
ieved 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 cholelithi
asis. 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 av
oidance or early recognition of iatrogenic bile duct injuries. IOC is
of most importance to compensate fundamental restrictions of the lapar
oscopic technique (missing possibility for palpation or anterograde pr
eparation). IOC adds additional safety to the laparoscopic procedure a
nd detects unsuspected bile duct stones. (2) At present, surgical mana
gement of cholecysto-/choledocholithiasis is splitted in two independe
nt procedures: LCE and pre- or postoperative endoscopic retrograde cho
langiography (ERC) with optional endoscopic papillotomy (EPT). A criti
cal 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 chole
lithiasis increases mortality and morbidity. Thus, the outcome of ther
apeutic splitting'' is not clearly superior to conventional treatment
by open surgery. The inconvenience for our patients caused by the oper
ation itself and one or more additional endoscopic procedures disagree
s with the principles of minimally invasive therapy and raises the ove
rall costs and the duration of treatment. (3) The transcystic anterogr
ade access to common bile duct exploration (CBDE) is recommended as an
alternative for the concept of ,,therapeutic splitting''. If CBD-ston
es are suspected or present, IOC with optional transcystic common bile
duct exploration allows final diagnosis and treatment in a single ses
sion. Additional risks and costs caused by choledochotomy as well as b
y pre- or postoperative endoscopic retrograde procedures (ERC, EFT) ar
e avoided. Techniques and equipment of IOC and transcystic common bile
duct exploration are presented in detail. Of 22 transcystic common bi
le duct explorations 20 were performed without complications. Two case
s required conversion to open surgery. The use of pulsed dye laser or
electro-hydraulic lithotripsy under direct endoscopic control is recom
mended for treatment of large and impacted stones. Randomized studies
for further evaluation of the different therapeutic modalities are urg
ently required.