SURGICAL-TREATMENT OF CHOLEDOCHOLITHIASIS

Following the introduction of endoscopic papillotomy and stone extract ion, surgical bile duct revision has decreased considerably in importa nce during the past mio decades. Surgical bile duct revision is associ ated with an appreciably higher rate of complications than endoscopic stone extraction. The result has been that most working groups now fav our a ''therapeutic splitting'' approach. This means that, wherever po ssible, endoscopic revision of the bile duct is first attempted. If, d uring laparoscopic cholecystectomy, intraoperative cholangiography rev eals the presence of bile duct stones, they may, after consultation wi th the endoscopist, be left in place for removal by endoscopic papillo tomy at some later date. Only in the case of very young patients and e xceptionally, a highly experienced laparoscopic surgeon may attempt a transcystic extraction of such stones. Continuing indications for conv entional surgical treatment of choledocholithiasis are local factors o bstructing access to the papilla (gastrectomy,, stenosis of the pyloru s) and other bile duct changes requiring correction (choledochocele, s trictures, stenoses, Mirizzi's syndrome, overlooked impacted stone obs tructing an overlong cystic duct stump, intrahepatic lithiasis).