Intraoperative cholangiography and anterograde bile duct exploration in laparoscopic cholecystectomy--technique, results, perspectives]

The avoidance of (unrecognized) bile duct injuries (1) and the management of bile duct stones (pre-, intra- or postoperatively?) (2) are believed 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 cholelithiasis. 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 avoidance or early recognition of iatrogenic bile duct injuries. IOC is of most importance to compensate fundamental restrictions of the laparoscopic technique (missing possibility for palpation or anterograde preparation). IOC adds additional safety to the laparoscopic procedure and detects unsuspected bile duct stones. (2) At present, surgical management of cholecysto-/choledocholithiasis is split in two independent procedures: LCE and pre- or postoperative endoscopic retrograde cholangiography (ERC) with optional endoscopic papillotomy (EPT). A critical 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 cholelithiasis increases mortality and morbidity. Thus, the outcome of "therapeutic splitting" is not clearly superior to conventional treatment by open surgery.2+ common bile duct exploration allows final diagnosis and treatment in a single session. Additional risks and costs caused by choledochotomy as well as by pre- or post-operative endoscopic retrograde procedures (ERC, EPT) are avoided.(ABSTRACT TRUNCATED AT 250 WORDS)