LAPAROSCOPIC CHOLECYSTECTOMY - THE EUROPEAN EXPERIENCE

Laparoscopic cholecystectomy, initially performed in France in 1987, h as rapidly spread to other European countries, the United States, and elsewhere. Of the techniques that have evolved, the ''French'' techniq ue, in which the surgeon stands between the patient's legs, and the '' American'' technique, in which the surgeon stands on the patient's lef t side, are the most commonly used. In the former technique, the liver is retracted via the mid-clavicular cannula and the infundibulum of t he gallbladder via the anterior axillary port. In the latter technique , the liver is retracted by axial traction on the gallbladder through the anterior axillary cannula and the infundibulum through the mid-cla vicular cannula. This position may increase the risk of bile duct inju ry. The technique selected for operative cholangiography should be ada pted to the problem at hand. Cystic duct cholangiography shows ductal calculi more reliably due to better filling of the common bile duct; d irect puncture of the gallbladder is safer when the biliary anatomy is unclear. A number of European studies confirm the safety of laparosco pic cholecystectomy. Mortality rates vary between 0% and 0.1%, and duc t injury rates range between 0.2% and 0.6%. Conversion, which is done in 3% to 8% of cases, may be necessary in the case of uncontrollable h emorrhage, bile duct injury unsuitable for laparoscopic repair, or if the gallbladder is densely scarred (scleroatrophic). It can also be do ne for safety reasons, when the anatomy is unclear. Complications incl ude bile collections due to accessory duct or cystic duct stump leaks or less commonly to common duct injury. The average postoperative stay is longer in Europe (3.2 days) than in the United States. A decision tree is presented for the management of common bile duct stones. In ge neral, preoperatively identified ductal stones are removed by endoscop ic sphincterotomy, which is then followed by laparoscopic cholecystect omy to remove the source of the calculi. The techniques of laparoscopi c choledochotomy and transcystic exploration for the removal of stones in the common bile duct are only beginning to be used, but they may w ell prove to be the most popular procedures. Results with these proced ures will need to be evaluated against those obtained with endoscopic sphincterotomy.