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241
Commentary
A Surgeon’s Perspective Cholecystectomy David
on Laparoscopic
W. Easter1
The “laparoscopic to gain
cholecystectomy revolution” continues The pace of its nearly complete accepby the medical and lay publics alike has been truly momentum.
tance astounding.
It is only natural
enthusiasm
crests,
one attempts
that after
the initial flood
of
to view this new modification
of an old operation in its proper perspective. This is the motivation and objective of the preceding article by Brandon et al. [1]. The authors have certainly chosen a timely subject, and they have done well to give us their views with the scant data available. Their first objective, to describe the history and evolution of laparoscopic cholecystectomy, warrants some expansion and clarifications. French surgeons were the first to perform successful Iaparoscopic removal of the gallbladder, as stated by Brandon et al. This method evolved from the truly pioneering work of Kurt Semm and his group in obstetrics and gynecology. The application
of these
methods
tion, ligature, and resection was a natural, if delayed,
of exposure,
retraction,
dissec-
of pelvic tissues to biliary disease sharing of technologies between
specialists. Furthermore, the diagnostic value of laparoscopic assessment of biliary disease antedated therapeutic biliary laparoscopy by at least 60 years [2]. Few surgeons recognized this valuable tool before the wildfire of laparoscopic cholecystectomy. But, as early as 1988, surgeons were prac-
ticing methods of laparoscopic gallbladder traction of stones, and mucosal ablation clear forerunners
This article 1
9981.
of the current
is a commentary
Department Address
AJR 157:241-242,
reprint
Division
requests
August
methods.
on the preceding
of Surgery,
cannulation, extechniques [3]-
of Surgical
article
by Brandon
Oncology,
University
The data available to date are certainly favorable to this new procedure when compared with the gold standard of open cholecystectomy. However, one must remember that the experiences reported to date are not only those of enthusiasts in the field of “minimal access surgery,” but those of very skilled surgeons who have, through natural selection if you will, been in the vanguard of this dramatic revolution. It
can be expected that when undertaken by the leagues of enthusiastic but less-experienced general surgeons, inferior results
/1 572-0241
occur.
trials,
This
projection
such
as those
will await
being
the
conducted
reports
of
by the
Society of American Gastrointestinal Endoscopic Surgeons (Los Angeles, CA), and possibly randomized prospective studies. But, unbiased randomization of patients into treatment groups with such different outcomes (at least in terms of postoperative comfort and recovery) may not be possible. With most surgical procedures, there are often as many variations as there are surgeons. Many surgeons would differ with some of the techniques reported by Brandon et al. A few of my preferences follow. Operative cholangiography should be routine for both open and laparoscopic cholecystectomy. There are many reasons for this view, including the possibility of finding incidental
stones in the common
bile duct. The most important
reason,
however, is to identify the structures to be ligated and divided before irreparable damage is caused. Cholangiography is a critical adjunct to visual inspection, especially for the beginner in laparoscopic techniques, in which perspectives are dra-
et al. of California,
San Diego,
to D. W. Easter.
1991 0361 -803X/91
will
prospective
© American
Roentgen
Ray Society
Medical
Center
(H-891B),
225 Dickinson
St., San Diego,
CA 921 03-
COMMENTARY
Downloaded from www.ajronline.org by 220.130.238.72 on 10/17/15 from IP address 220.130.238.72. Copyright ARRS. For personal use only; all rights reserved
242
AJR:157,
August
1991
matically altered. Furthermore, cholangiography gives the best chance of recognizing injuries when they occur. Early recognition of such complications is crucial to their successful management. Routine laparoscopic cholangiography also is critical if surgeons are to become sufficiently skilled to perform cholangiography when required by the clinical situation. Furthermore, these skills are the natural first step toward laparoscopic exploration of the common bile duct-a procedure already being practiced by some experienced surgeons. There are many options for dealing with stones in the common bile duct. My preference for known or suspected choledocholithiasis (such as the unusual case detected by sonography), is to clear the stones endoscopically on the day before planned laparoscopic cholecystectomy. The patient who recovers quickly (as expected) from an episode of gallstone pancreatitis does not require preoperative endoscopic cholangiography. If tiny stones are found during operative cholangiography, an attempt is made to wash the “gravel” through the sphincter of Oddi with saline irrigation through the cystic duct catheter. A second set offllms will often show clearance of the common bile duct. If the common bile duct is of normal caliber and residual stones are trivial in size, I recommend completing the cholecystectomy and endoscopically clearing the duct in the first few days after surgery. Finally, if stones are substantial
associated with laser dissection. The tenth was questionably so. We think that laser dissection should be evaluated on its own merit separately from laparoscopic techniques, and moreover should not be performed by surgeons inexperienced in laparoscopy [4] (Moossa AR, Easter DW, unpublished data). This caution should lower the chance of bile duct injury during the learning curve with this new technique. The beginning laparoscopist should be proctored by one who already has training and significant experience with both laparoscopy and open cholecystectomy. Experience has no equal when a difficult or unexpected situation is encountered in the operating room. Finally, special emphasis should be placed on informed consent. Every patient must understand the very real possibility of conversion to an open procedure. Conversion to open cholecystectomy should not be viewed as a failure of the Iaparoscopic methods, but rather as an intraoperative decision meant to minimize risk to the patient. In the past 10 years, the medical community has witnessed significant advances in the alternatives for dealing with biliary calculi. With experience, we will learn which options are best for which patients. I eagerly await the objective comparison of laparoscopic cholecystectomy with conventional cholecystectomy and the alternative treatment methods available.
in number
REFERENCES
or size,
or if the
bile duct
is enlarged,
“open”
exploration of the common bile duct is warranted. As we gain further experience with laparoscopic methods, options for dealing with this particular problem will certainly increase. The use of laser energy for dissection and hemostasis by the inexperienced laparoscopic surgeon adds unnecessary hazards. We have recently had 10 referrals to our hospital for surgical
reconstruction
of laparoscopic
injuries to the common
bile duct and hepatic ducts. Nine of these injuries were clearly
1 . Brandon JC, Velez MA, Teplick 5K, et al. Laparoscopic cholecystectomy: evolution, early results, and impact on nonsurgical gallstone therapies. AiR 1991;157:235-239 2. KaIk, H. Ertahrungen mit der laparoscopie (Zugleich mit Beschreibung ames neuen Instrumentes.) Z KIm Med 1929;11 1:303-348 3. Cuschien A, Abd el Ghany AA, Holley MP. Successful chemical cholecystectomy: a laparoscopic guided technique. Gut 1989;30: 1786-1 794 4. Easter DW, Moossa AR. Laser and laparoscopic cholecystectomy-a hazardous union? Arch Surg 1991;126:423
241
Commentary
A Surgeon’s Perspective Cholecystectomy David
on Laparoscopic
W. Easter1
The “laparoscopic to gain
cholecystectomy revolution” continues The pace of its nearly complete accepby the medical and lay publics alike has been truly momentum.
tance astounding.
It is only natural
enthusiasm
crests,
one attempts
that after
the initial flood
of
to view this new modification
of an old operation in its proper perspective. This is the motivation and objective of the preceding article by Brandon et al. [1]. The authors have certainly chosen a timely subject, and they have done well to give us their views with the scant data available. Their first objective, to describe the history and evolution of laparoscopic cholecystectomy, warrants some expansion and clarifications. French surgeons were the first to perform successful Iaparoscopic removal of the gallbladder, as stated by Brandon et al. This method evolved from the truly pioneering work of Kurt Semm and his group in obstetrics and gynecology. The application
of these
methods
tion, ligature, and resection was a natural, if delayed,
of exposure,
retraction,
dissec-
of pelvic tissues to biliary disease sharing of technologies between
specialists. Furthermore, the diagnostic value of laparoscopic assessment of biliary disease antedated therapeutic biliary laparoscopy by at least 60 years [2]. Few surgeons recognized this valuable tool before the wildfire of laparoscopic cholecystectomy. But, as early as 1988, surgeons were prac-
ticing methods of laparoscopic gallbladder traction of stones, and mucosal ablation clear forerunners
This article 1
9981.
of the current
is a commentary
Department Address
AJR 157:241-242,
reprint
Division
requests
August
methods.
on the preceding
of Surgery,
cannulation, extechniques [3]-
of Surgical
article
by Brandon
Oncology,
University
The data available to date are certainly favorable to this new procedure when compared with the gold standard of open cholecystectomy. However, one must remember that the experiences reported to date are not only those of enthusiasts in the field of “minimal access surgery,” but those of very skilled surgeons who have, through natural selection if you will, been in the vanguard of this dramatic revolution. It
can be expected that when undertaken by the leagues of enthusiastic but less-experienced general surgeons, inferior results
/1 572-0241
occur.
trials,
This
projection
such
as those
will await
being
the
conducted
reports
of
by the
Society of American Gastrointestinal Endoscopic Surgeons (Los Angeles, CA), and possibly randomized prospective studies. But, unbiased randomization of patients into treatment groups with such different outcomes (at least in terms of postoperative comfort and recovery) may not be possible. With most surgical procedures, there are often as many variations as there are surgeons. Many surgeons would differ with some of the techniques reported by Brandon et al. A few of my preferences follow. Operative cholangiography should be routine for both open and laparoscopic cholecystectomy. There are many reasons for this view, including the possibility of finding incidental
stones in the common
bile duct. The most important
reason,
however, is to identify the structures to be ligated and divided before irreparable damage is caused. Cholangiography is a critical adjunct to visual inspection, especially for the beginner in laparoscopic techniques, in which perspectives are dra-
et al. of California,
San Diego,
to D. W. Easter.
1991 0361 -803X/91
will
prospective
© American
Roentgen
Ray Society
Medical
Center
(H-891B),
225 Dickinson
St., San Diego,
CA 921 03-
COMMENTARY
Downloaded from www.ajronline.org by 220.130.238.72 on 10/17/15 from IP address 220.130.238.72. Copyright ARRS. For personal use only; all rights reserved
242
AJR:157,
August
1991
matically altered. Furthermore, cholangiography gives the best chance of recognizing injuries when they occur. Early recognition of such complications is crucial to their successful management. Routine laparoscopic cholangiography also is critical if surgeons are to become sufficiently skilled to perform cholangiography when required by the clinical situation. Furthermore, these skills are the natural first step toward laparoscopic exploration of the common bile duct-a procedure already being practiced by some experienced surgeons. There are many options for dealing with stones in the common bile duct. My preference for known or suspected choledocholithiasis (such as the unusual case detected by sonography), is to clear the stones endoscopically on the day before planned laparoscopic cholecystectomy. The patient who recovers quickly (as expected) from an episode of gallstone pancreatitis does not require preoperative endoscopic cholangiography. If tiny stones are found during operative cholangiography, an attempt is made to wash the “gravel” through the sphincter of Oddi with saline irrigation through the cystic duct catheter. A second set offllms will often show clearance of the common bile duct. If the common bile duct is of normal caliber and residual stones are trivial in size, I recommend completing the cholecystectomy and endoscopically clearing the duct in the first few days after surgery. Finally, if stones are substantial
associated with laser dissection. The tenth was questionably so. We think that laser dissection should be evaluated on its own merit separately from laparoscopic techniques, and moreover should not be performed by surgeons inexperienced in laparoscopy [4] (Moossa AR, Easter DW, unpublished data). This caution should lower the chance of bile duct injury during the learning curve with this new technique. The beginning laparoscopist should be proctored by one who already has training and significant experience with both laparoscopy and open cholecystectomy. Experience has no equal when a difficult or unexpected situation is encountered in the operating room. Finally, special emphasis should be placed on informed consent. Every patient must understand the very real possibility of conversion to an open procedure. Conversion to open cholecystectomy should not be viewed as a failure of the Iaparoscopic methods, but rather as an intraoperative decision meant to minimize risk to the patient. In the past 10 years, the medical community has witnessed significant advances in the alternatives for dealing with biliary calculi. With experience, we will learn which options are best for which patients. I eagerly await the objective comparison of laparoscopic cholecystectomy with conventional cholecystectomy and the alternative treatment methods available.
in number
REFERENCES
or size,
or if the
bile duct
is enlarged,
“open”
exploration of the common bile duct is warranted. As we gain further experience with laparoscopic methods, options for dealing with this particular problem will certainly increase. The use of laser energy for dissection and hemostasis by the inexperienced laparoscopic surgeon adds unnecessary hazards. We have recently had 10 referrals to our hospital for surgical
reconstruction
of laparoscopic
injuries to the common
bile duct and hepatic ducts. Nine of these injuries were clearly
1 . Brandon JC, Velez MA, Teplick 5K, et al. Laparoscopic cholecystectomy: evolution, early results, and impact on nonsurgical gallstone therapies. AiR 1991;157:235-239 2. KaIk, H. Ertahrungen mit der laparoscopie (Zugleich mit Beschreibung ames neuen Instrumentes.) Z KIm Med 1929;11 1:303-348 3. Cuschien A, Abd el Ghany AA, Holley MP. Successful chemical cholecystectomy: a laparoscopic guided technique. Gut 1989;30: 1786-1 794 4. Easter DW, Moossa AR. Laser and laparoscopic cholecystectomy-a hazardous union? Arch Surg 1991;126:423
