Laparoscopic cholecystectomy for biliary tract emergencies: State of the art

Although laparoscopic cholecystectomy is unusually safe and well tolerated in patients with routine symptomatic cholelithiasis, it can become a formid able procedure when used to manage biliary tract emergencies. Optimally, a reasoned and cautious approach and a low threshold for conversion can avoid major complications. One such emergency, acute cholecystitis, may be parti cularly hazardous because of the relatively common finding of severe inflam mation with dense adhesions to adjacent viscera and gallbladder necrosis. S pecial modifications of technique may be required. Overall, urgent operatio n (within 72 hours) results in an acceptably low mortality (0.3%) but a som ewhat higher conversion rate (16%) and longer hospital stay (3 days). Unnec essary delays may result in more adhesions and an increased level of operat ive difficulty. In patients who are at an especially high risk because of c o-morbid disease, percutaneous cholecystostomy is an appropriate alternativ e strategy. Biliary pancreatitis may be associated with high mortality (9%) and has an unpredictable course. Accordingly, a multidisciplinary approach that may include both gastroenterologists and radiologists is generally ad visable. Because common bile duct (CBD) stones are present in more than 20% of patients who present with biliary pancreatitis, endoscopic retrograde c holangiopancreatography (ERCP) can be used effectively on a selective basis during the preoperative or postoperative period; the preferred timing cont inues to be somewhat controversial. As an alternative approach, laparoscopi c CBD exploration is gradually gaining wider acceptance. In eight reported series using a variety of techniques for stone extraction, major complicati ons were infrequent (10%), and the conversion rate was low (5%). Acute supp urative cholangitis is a more fulminant problem that is best managed by exp editious ERCP with removal of all intraductal stones. Resuscitation should be continued until complete; laparoscopic cholecystectomy can follow at an appropriate interval.