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

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.