Laparoscopic cholecystectomy: an analysis of 777 cases J. PERISSAT D. COLLET M. EDYE E. MAGNE R. BELLIARD J. DESPLANTEZ

INTRODUCTION We started our laparoscopic approach to gallstones in November 1988 and had performed our first 100 cholecystectomies by December 1989 (Perissat et al, 1990b). Since then, new instruments have become available, new results have been published, and numerous teams have started working in the field. By September 1991 we had carried out 777 consecutive laparoscopic cholecystectomies. The aim of this chapter is to report the results of these procedures and describe the evolution of our indications and operative technique. OPERATIVE


The patient is positioned supine, legs separated with the surgeon between. The head of the table is raised and tilted to the left to encourage the colon and duodenum to fall away from the liver. The degree to which the patient can be positioned in this way depends upon anaesthetic considerations and the stabilization of the patient on the table. A nasogastric tube is positioned to flatten the stomach. Initial pneumoperitoneum is established by Verres needle puncture in the left upper quadrant. A lo-mm trocar for a 0” or 30” axial laparoscope is inserted at the umbilicus, a second below the left costal margin, and two 5-mm cannulae are placed laterally below the right costal margin for the manipulation and irrigation instruments (Figure 1). The cystic duct is identified and isolated with scissor, hook and blunt dissection, clipped close to the gallbladder and incised transversely to permit insertion of a narrow catheter for operative cholangiography using an image Bailli2re’s Clinical GastroenterologyVol. 6, No. 4, November 1992 ISBNO-702&1625-X

727 Copyright 0 1992, by Baillikre Tindall All rights of reproduction in any form reserved





Figure 1. Cannula entry sites: (1) laparoscope; (2) dissector, scissors, diathermy, clip applier; (3) sucker/irrigator as liver retractor; (4) grasper.

intensifier. Demonstration of the anatomy during this dissection is extremely precise and is facilitated by retracting the gallbladder inferolaterally, away from the liver and bile duct, thus spreading out the triangle of Calot (Figures 2 and 3). Once the cholangiogram has demonstrated satisfactory passage of contrast into the duodenum, no filling defects and a good view of the common hepatic and intrahepatic ducts, the catheter is withdrawn and the cystic duct is doubly clipped before being divided. One or more endoligatures should also be available for closure of the cystic duct stump if it is friable due to inflammation and clips are likely to cut through. Diathermy should be used sparingly close to the common bile duct (CBD) due to the risk of aberrant conduction causing a full-thickness burn to the duct wall, which may present as a bile leak some days later. Having secured with clips and divided the cystic artery or its branches, the gallbladder is detached from its bed in the gallbladder fossa. Depending on the size of the calculus, it can be withdrawn through one of the larger cannula sites with a little dilatation of the abdominal fascia. Alternatively, calculi can be pulverized with an ultrasonic lithotripter or crushed mechanically in the jaws of a surgical clamp allowing easy extraction of the gallbladder. If the wall of the gallbladder has been breached during the dissection or is inflamed and fragile, it can be enclosed in a stout plastic bag which is then withdrawn through the abdominal wall, thus containing any spillage of stones or bile.




Figure 2. Safe display of the triangle of Calot, which is well spread out.


Figure 3. Dangerous display of the triangle of Calot: cramped with cystic and bile ducts parallel.

After extraction of the gallbladder, the position of clips on the cystic artery and duct is checked. Extensive irrigation is performed with isotonic saline solution at 37°C until the liquid is clear. At present we are more selective and drain in cases of acute or gangrenous cholecystitis where the cystic duct is fragile, or large and inflamed, and has been ligated as clips would not be reliable. After checking each puncture site for haemostasis, the pneumoperitoneum is fully evacuated by depressing the valves of the




cannulae, which are then removed. To minimize scarring the lo-mm incisions are closed with a subcuticular stitch and wound edges are approximated with sterile adhesive strips. Postoperative management As the operation is performed under general anaesthesia, all our patients remain in hospital at least overnight. The following day they can eat and walk normally. They are allowed to leave hospital at their own request and when we know that there will be good medical follow-up at home from their family doctor. Many patients prefer to spend an extra night in hospital and return home on the second postoperative day. We advise a convalescent period of 1 week before resuming normal physical activity, and an additional week before returning to work. Some of the more active and highly motivated patients have returned to work a week after their operation. THE PATIENTS From November 1988 to September 1991 we performed laparoscopic cholecystectomies in 777 patients, whose sex and age are indicated in Table 1. These patients are a mixed group in that they are spread out over time, and our criteria for selection and operating techniques evolved over that same period. They can be divided into three groups. Table 1. Results of laparoscopic cholecystectomy performed in 777 patients* from November 1988 to September 1991. No. of deaths Conversion to laparotomy No. of complications Common bile duct injury



1 43 26 3

0.1 5.5 3.3 0.4

* 582 females, 195 males; age range 13-83 years.

Group 1. This group consisted of our first 104 patients, operated on from November 1988 to December 1989. Since we were in practically unknown territory, patients who were suffering from uncomplicated biliary colic were deliberately selected for this new procedure to the exclusion of those with acute cholecystitis or a history of numerous previous inflammatory attacks. We also excluded patients with CBD stones, cardiorespiratory risk factors, however small, and pregnant women. We did not eliminate obese patients. Figure 4 summarizes our selection criteria. Preoperative investigations included a cardiorespiratory assessment, a hepatic assessment with hepatic function tests based on cholestasis (bilirubin, transaminases, alkaline phosphatase, Gamma-GT), ultrasonography



of the liver and biliary tract, and intravenous cholangiography (IVC) with tomography. If duct visualization was poor (with obese patients in particular), endoscopic retrograde cholangiopancreatography (ERCP) was performed. ,-b

No treatment

Mild, infrequent


ESWL + dissolution

Severe, frequent


Laparoscopic surgery

Asymptomatic stones Biliary colic Acute cholecystitis

Open surgery

Long history of repeated attacks Figure 4. Selection criteria for treatment of gallstones in the first 104 patients (group 1).

Group 2. There were 617 patients in this group. The only absolute contraindications were the existence of an unstable cardiac state or previous upper abdominal surgery affecting the stomach, liver or pancreas. In this group, 161 patients were operated on semi-urgently for acute cholecystitis. Sixty-three patients had a long history of bouts of acute cholecystitis treated medically. None of these patients presented with symptoms, either in the past or more recently, that might have suggested the presence of CBD stones, although we looked routinely for the presence of asymptomatic stones. Preoperative investigations were as for group 1, except that cholangiography was performed only in specific circumstances. If ultrasonography showed a CBD calibre of 8mm or more, ERCP was performed. If ultrasonography was normal but the hepatic function tests showed abnormalities (elevated alkaline phosphatase or Gamma-GT), IVC with tomography was performed or, in the case of an overweight patient, ERCP, as the IVC can often be misleading in these patients. Group 3. The 56 patients in this group had been referred for treatment of gallstones; their principal symptoms were due to the presence of CBD stones. All of these patients had stones in the gallbladder. They underwent the same cardiorespiratory and hepatobiliary function assessments as patients in groups 1 and 2, and, in addition, all underwent ERCP. RESULTS Complications

for patients in all three groups are summarized in Table 2.

Group 1 The results for this group are discussed here only briefly since they have already been published (Perissat et al, 1990). Mortality was nil. The



Table 2. Results of laparoscopic cholecystectomy in the three groups (777 patients) from November 1988 to September 1991. No. of deaths

No. of conversions

No. of complications

Group 1 (n = 104) Group 2 (n = 617) Group 3 (n = 56)

0 1 0

3 36 4


1 (0.1%)

43 (5.5%)

Common bile duct injury

3 23 0 26 (3.3%)

0 3 0 3 (0.4%)

laparoscopy had to be converted into a laparotomy in three cases and there were three postoperative complications, none of which required open surgery. In this very select group of patients, in whom the only symptom was biliary colic with no inflammatory features, either recently or in the patient’s history, the preoperative assessment detected asymptomatic calculi in the CBD in three cases and these were treated by endoscopic sphincterotomy prior to laparoscopic cholecystectomy. The majority of patients had a subhepatic drain for 24 h. These excellent results, combined with the fact that we had gained operating experience and that instruments more specific to coelioscopic biliary surgery had become available, enabled us to widen our indications (Figure 5). Asymptomatic stones --+ Symptomatic stones -+ l If cholestatic picture or common bile duct > 8 mm l

If big stones -+

No treatment Exploratory laparoscopy Laparoscopic cholecystectomy if technically feasible Preoperative ERCP f

l sphincterotomy

Operative lithotripsy

Figure 5. Current selection criteria for the treatment of patients with gallstones.

Group 2

There was one death in this group: an 82-year-old woman operated on semi-urgently for acute cholecystitis who died without warning 48 h after the operation while sitting in her chair. No autopsy was carried out and the cause of this sudden death remains unknown. The laparoscopic procedure had to be converted to an open operation in 36 patients (Table 3). It should be noted that 27 of these conversions took place in the group which presented with either acute cholecystitis or a gallbladder profoundly altered by previous bouts of inflammation, described as sclero-atrophic. Here the gallbladder is difficult to grasp because it is thick walled, contracted tightly around its contained calculus, and contains little or no fluid. Because of scarring, there is no surgical plane




Table 3. Conversions (n = 36) to laparotomy in group 2 (617 patients). Acute cholecystitis (n = 161) Bleeding Adhesions CBD injury CBD stones Gallbladder perforation Confusing anatomy Equipment failure Total

3 4 1 3 1 0 1 13 (8.1%)

Inflamed gallbladder (n = 63)

Non-infected gallbladder (n = 393)

3 10 1 0 0 0 0

3 1 0 1 0 1 3

14 (22.2%)

9 (2.3%)

between it and the liver. The most frequent reasons for conversion were uncontrolled bleeding and dense adhesions around the gallbladder. There were four cases of bleeding of the cystic artery or branches, three cases of bleeding in the gallbladder bed, and two cases where conversion was required due to the existence of portal hypertension secondary to cirrhosis undetected during the preoperative assessment. The gallbladder can be buried under dense adhesions made up of the greater omentum, the hepatic flexure of the colon, and the duodenum. As there is a significant risk of damaging the colon and/or the duodenum, dissection by electrocoagulation should be kept to a minimum and bipolar diathermy used if available. In 11 cases the laparoscopic procedure was abandoned because of the density of these adhesions. In four cases the dense hepatic attachments of an intrahepatic sclero-atrophic gallbladder caused us to beat a retreat. Two injuries to the CBD occurred and were detected intraoperatively, one lateral and one complete division where the CBD was mistaken for the cystic duct. A conversion to laparotomy enabled the first patient to be treated by insertion of a T-tube and the second by end-to-end repair. In one case, attempted lithotripsy with the gallbladder in place in a patient with gangrenous cholecystitis ended with multiple perforations of the gallbladder wall from the grasping forceps, from which stones escaped into the peritoneum. Laparotomy was necessary to terminate the cholecystectomy and completely lavage the peritoneal cavity. The postoperative course was uncomplicated. Four cases of asymptomatic CBD stones led us to convert to laparotomy, on three occasions in an emergency procedure for acute cholecystitis where a thorough preoperative assessment had not been possible, and in the fourth case a stone suspected prior to surgery was confirmed by operative cholangiography. In none of these cases was it possible to remove the stone by transcystic laparoscopic techniques. There were 25 postoperative complications in this group. Three required a second open surgical procedure. In one case a partial stenosis of the CBD was revealed due to a haemostatic clip on the cystic artery pinching and partially occluding the common hepatic duct. Because of the development of jaundice by the fifth postoperative day, the patient underwent reoperation to remove




the clip. Although the compressed region showed a loss of wall thickness, there was no defect of the mucosa, but we elected to insert a small T-tube. The postoperative course was uncomplicated. The second case was one of shock due to substantial bleeding 2 h after laparoscopic cholecystectomy in a patient with cirrhosis. Laparotomy and packing of the gallbladder bed was necessary to achieve haemostasis. The postoperative course was uneventful. The third patient developed an abscess in the pouch of Douglas necessitating a laparotomy on the ninth postoperative day. The remaining complications are summarized in Table 4. Table 4. Postoperative complications* in group 2 (617 patients) Acute cholecystitis (n = 161) Bleeding Bile leak CBD stenosis Intra-abdominal abscess Acute pancreatitis Acute ascites PUO(Pyrexia of unknown origin) Other


i 1 0 1


8 (5.0%)

2 0

Inflamed gallbladder

Non-infected gallbladder

(n = 63)

(?I = 393)

2 3 0 30

0 1 2

11 (17.5%)

1 0

1 1 0 1 1 6


* 25 complications; 4.1%.

Complications were classified, according to their appearance in time in the postoperative period, into ‘early’ (48 h after operation), ‘intermediate’ (appearing from day 2-20) and ‘late’ (after day 20) complications (Table 5). Early complications included major bleeding, mentioned above, and two biliary leaks adequately dealt with by the subhepatic drain placed at operation for acute cholecystitis. The spontaneous cessation of bile drainage after 5-7 days, following an initial flow of 400 ml per day, prompted us not to pursue, the origin of the leak as this would have entailed ERCP, itself not without risk. A case of acute pancreatitis also occurred within 48 h in a patient with microlithiasis of the gallbladder and a very narrow CBD with no stones evident on the operative cholangiogram. We are not certain of the reason for this episode, which settled on medical treatment. Intermediate complications were bleeding, biliary effusions and intraabdominal sepsis. Secondary haemorrhage was suspected when pain occurred about the fifth postoperative day after the patients had returned home, and was supported by the finding of significant anaemia and a subhepatic collection which showed on ultrasonography. Treatment was not undertaken and the symptoms resolved spontaneously. Follow-up sonograms showed a small, resolving subhepatic collection. Three biliary effusions occurred as intermediate symptoms manifested by pain in the right hypochondrium and a fever between 37S”C and 38°C which




Table 5. Timing of 25 complications after surgery in group 2 (617 patients). Early Bleeding Bile leak CBD stenosis Intra-abdominal Other Total




1 2 0 0 2

3 3 1 5 6

0 0 0 2 0




appeared following a week free of symptoms and after the patients’ discharge. The effusion was diagnosed in all three cases by ultrasonography. In one, ERCP showed a leak from the cystic duct stump where the clip was not tight enough. The CBD was dilated but showed no signs of calculi or stenosis of the sphincter of Oddi, and the effusion was evacuated by means of an echo-guided puncture and positioning of a drain. There was no further biliary discharge and the drain was removed after 24 h. In the second, a further laparoscopy showed a subhepatic biliary effusion of which we were unable to find the origin and which resolved in 1 week with simple drainage. In the last case, a leak from the cystic duct resolved in 1 week by combining laparoscopically placed drainage and endoscopic sphincterotomy. Five cases of intra-abdominal abscess in the subhepatic region appeared in the 10 days following operation and after the patients had been at home for at least 1 week. The clinical picture was consistent: throbbing pain in the right hypochondrium accompanied by fever. The diagnosis was confirmed by ultrasonography and the finding of leucocytosis. Treatment consisted of a second laparoscopy followed by evacuation of the collected fluid, irrigation and insertion of a suction drain. Resolution occurred in 48 h. All the patients had a straightforward recovery. It should be noted that four of these abscesses occurred after difficult cholecystectomy, one in a patient with acute cholecystitis and three following laparoscopic cholecystectomy for a very inflamed sclero-atrophic gallbladder. In all these cases, no drain had been placed at operation. The remainder of the intermediate complications in group 2 were more diverse: one bout of acute ascites in a patient with cirrhosis 2 weeks after cholecystectomy, three medical complications of a general nature (heart failure, pulmonary infection and a fever which lasted 10 days and disappeared as suddenly as it had started). Two patients developed an abscess in the pouch of Douglas which appeared respectively on days 20 and 24. The clinical picture was typical, with pelvic pain and fever. Diagnosis was confirmed by ultrasonography. Both patients were treated by a second laparoscopy which enabled irrigation and drainage of the purulent fluid. Each abscess contained calculous debris which had escaped from the gallbladder at the time of its extraction. Such debris may not be as innocuous as some would suggest. Recovery was straightforward.




We should underline the fact that of the 25 complications in 617 patients treated, 19 appeared in the group of 224 patients operated on for inflammation or acute cholecystitis. Thirty-five clinically asymptomatic stones of the CBD were discovered in group 2 patients (Table 6). In 28 cases they were discovered during the preoperative assessment. They were all treated by endoscopic sphincterotomy, generally prior to laparoscopic cholecystectomy. In three cases the Table 6. Asymptomatic group 2 (617 patients).

common bile duct stones* in n

Detected before LC Treated by ERCP + sphincterotomy Before During LC After LC Total Detected during LC Treated by ERCP + sphincterotomy Conversion to laparotomy Total

19 3 6 28 3 4 7

* 35 stones; 5.7%. LC, laparoscopic cholecystectomy; ERCP, endoscopic retrograde cholangiopancreatography.

duct was cleared by endoscopic sphincterotomy during operation. However, since the patients are supine, it is difficult to gain access to the papilla by duodenoscopy so we shelved the idea of combining the two techniques. In six cases we decided to perform laparoscopic cholecystectomy first. A drain was secured in the cystic duct and endoscopic sphincterotomy carried out 2 days after laparoscopic cholecystectomy. In seven cases the stone was found during laparoscopic cholecystectomy by operative cholangiography. In six of these patients had undergone an emergency operation for acute cholecystitis and had not had a preoperative assessment. In the remaining case, the patient had undergone an elective procedure with no symptoms of cholestasis, and ultrasonography of the CBD had been normal. Since the size of the cystic duct was more than 2 mm, intraoperative cholangiography was carried out which showed the stone. In three cases we elected to leave the stone in place to be extracted 48 h later by endoscopic sphincterotomy. In the four other cases, using the same sequence of operation, we decided to convert the laparoscopy into a laparotomy in order to be able to treat a stone in the CBD by choledochotomy followed by a temporary transcystic drain. A subhepatic drain was placed in 106 patients. In three cases a biliary effusion was transformed into a fistula and biliary peritonitis thus avoided. In one case, massive bleeding was detected rapidly, leading to laparotomy. The six cases of intermediate or late intra-abdominal sepsis occurred in patients without a drain. Patients with no complications or conversion to laparotomy had a recovery period free from pain and were able to resume normal physical




activity less than 1 week after the operation. The mean postoperative stay in hospital was 2.8 days (range l-7 days). All the patients with no complications were reviewed 4 weeks after laparoscopic cholecystectomy, and those with a complication requiring surgical or endoscopic treatment were reviewed 4 weeks after the last procedure. There was no evidence of medium-term complications. In this series, 132 patients were reviewed 1 year after the operation during a visit which included ultrasonography and the liver function tests mentioned above. No complications came to light, either locally (at the point of insertion of the cannulae) or at the biliary level (no residual CBD stones). Group 3

This group consisted of 56 patients who all had clinical symptoms suggesting the presence of a stone in the CBD (Table 7), either at the time of admission or shortly before (l-2 weeks previously). Four presented with severe cholangitis without kidney failure and negative blood cultures. Of these, two had hyperamylasaemia, compatible with acute pancreatitis. All 56 patients underwent ERCP. Table 7. Clinical features of 56 patients with common bile duct stones in group 3. n Abnormal liver function tests CBD dilatation on sonogram ERCP CBD stones CBD clear

55 48 43 13

In 43 patients a stone was found in the CBD associated with a dilated biliary tract and a feature of cholestasis. In one case the stone was situated in an undilated biliary tract with no signs of cholestasis. In seven patients with biochemical cholestasis the CBD was dilated but free of stones. In six with biochemical cholestasis, the CBD was of normal calibre and free of stones. We carried out 49 endoscopic sphincterotomies: in 43 patients in order to clear the CBD and in six patients to open a papilla which was thought to be stenosed because of biliary tract dilatation in the absence of identifiable stones. These 56 patients were to undergo laparoscopic cholecystectomy immediately after clearance of the duct. This operation was performed in 32 cases on the day after the endoscopic sphincterotomy, in nine on day 2, and in eight between days 3 and 8. For the remaining seven patients, sphincterotomy was performed for severe cholangitis and laparoscopic cholecystectomy was deferred. In four cases we elected to perform traditional cholecystectomy: two




patients had presented with hyperamylasaemia suggestive of acute pancreatitis at the time of onset of cholangitis; in one case there was a residual stone after the endoscopic sphincterotomy and we elected to remove it by choledochotomy during traditional cholecystectomy; and in the fourth case ultrasonography had shown an empyema and we preferred to perform a traditional procedure. It should be stressed that in none of the groups was a complication due to pneumoperitoneum. Some authors report complication rates of 0.19% and greater. COMMENTS Initially our indications were very narrow, with many patients being excluded on the grounds mentioned above. Once we had reached our 100th patient, our indications were expanded so that the 40% of initial referrals considered to be contraindicated dropped to 18%. The results obtained in these first 104 cases were far better than those obtained by traditional cholecystectomy, but if an assessment is made of the overall results, the mortality and morbidity rates (Tables 1 and 8) can be seen to be largely identical to those obtained by traditional procedures (Table 9). The expansion of our indications meant that our rate of conversion to laparotomy increased from 3% to 5.5%. Postoperative complications remained stable (3% to 4.1%) but there were three lesions of the CBD and one death. Table 8. Results of cholecystectomy by open surgery.

% Mortality rate Morbidity rate Linked to laparotomy Linked to common bile duct Reoperation (for retained stones)

0.5 4.2 0.4 0 0.7

From Ganey et al (1986). Table 9. Results of cholecystectomy by laparoscopic surgery in the France-Belgian series: 3708 cases. % Mortality rate Conversion rate Morbidity rate Linked to conversion Linked to common bile Reoperation

0.13 7.0 3.5 0 duct

From Testas and Delaitre (1991).






These results must be analysed in relation to the pathological state of the gallbladders removed and the level of our expertise at the time of laparoscopic cholecystectomy. As for patients with non-inflamed gallbladders (ail of those in group 1 and most of those in group 2; see Table 2), the conversion rate remained essentially unchanged (3%) 2.3%). The rate of postoperative complications decreased by half (from 3% to 1.4%). This decrease was balanced by a higher complication rate when acute or chronic inflammation was present (such as sclero-atrophic gallbladder). It was in this last subgroup of patients that the highest percentage of complications occurred (11 of 63 cases, 17%) and the conversion rate reached 22%. Do such results cast doubt on the advisability of laparoscopic cholecystectomy in such patients? It is perhaps useful at this point to recall the clinical profile of such patients: they have a long history of bouts of acute cholecystitis, with the gallbladder wall more than 4 mm thick, as shown by ultrasonography, and very little fluid around the stones. The best indicator remains the laparoscopic appearance showing dense adhesions around a very small gallbladder buried deep in the hepatic parenchyma. It is relatively easy to foresee these difficulties before operation from the history and the sonogram. Patients should therefore be told that the likelihood of completing the procedure laparoscopically is 60-70%. In the near future we should see the rate of postoperative complications falling for this group of patients, at the price of an increase in the percentage of conversions, which in turn will decrease as the experience of laparoscopic teams increases. We believe cholecystectomy should begin at least with exploratory laparoscopy as two thirds of such patients will benefit. Indeed, it is in the speed and comfort of the postoperative recovery that laparoscopic cholecystectomy is a major step forward. Usually there is no pain, the abdominal wall remains soft, digestive function returns quickly, and normal physical activity can be resumed almost immediately. The disadvantages are more often than not associated with anaesthesia, with nausea and sleepiness for a number of hours. Progress is needed in the choice of anaesthetic agent or in the avoidance of general anaesthesia altogether. If rapid recovery does not occur after laparoscopic cholecystectomy, a complication should be suspected. Complications usually occur immediately or early in the postoperative period. Pain, tenderness of the abdominal wall, temperature or slight jaundice are all signs that should prompt immediate investigation, either to prevent the complication or to treat it as rapidly as possible. The main examination techniques available are ultrasonography, computed tomography, ERCP, white cell count, and tests for cholestasis and cytolysis. Bleeding and biliary leaks can thus be detected. One does not necessarily need to resort to open surgery to resolve these problems. Often medication or a second laparoscopy is sufficient and effective. If postoperative recovery is a little prolonged, the patient has not lost the benefit of avoiding a large abdominal wound. The excellent recovery from laparoscopic cholecystectomy should also be offered to patients with calculi in the CBD associated with gallbladder stones. If the stone in the CBD is clinically symptomatic, this should be treated first. Currently, endoscopic sphincterotomy after ERCP gives excellent results.




Once the CBD is clear, laparoscopic cholecystectomy can be performed on the following day or a few days later. Thus comprehensive treatment is available for gallstones, wherever they are located, by endoscopic means, combining endoluminal endoscopy and laparoscopy. Asymptomatic CBD stones should also be sought routinely. Progress in preoperative investigations is such that few stones are missed. Once the stone has been discovered it must be removed by endoscopic sphincterotomy and laparoscopic cholecystectomy deferred for a day or so. Our continued pursuit of asymptomatic CBD stones prior to laparoscopic cholecystectomy is justified by the fact that it is not possible at present routinely to clear the CBD using laparoscopic techniques. In addition, in 510% of cases (depending on the operator’s experience) it is technically impossible to carry out an endoscopic sphincterotomy. It would be detrimental to take the patient down the following path: laparoscopic cholecystectomy-discovery of an asymptomatic stone in the CBD that cannot be removed-failure of the subsequent endoscopic sphincterotomylaparotomy, choledochotomy and removal of the CBD stone. In this field techniques are evolving rapidly and a standardized approach to the CBD during laparoscopy will evolve in the near future. At that time the advantages and disadvantages of this new technique must be evaluated and compared with those of endoscopic sphincterotomy, which until now has given the best results. New techniques which gain a place as rapidly in the therapeutic armamentarium as laparoscopic cholecystectomy has done are few and far between. Following initial reports of the procedure (Perissat et al, 1989; Reddick and Olsen, 1989; Dubois et al, 1990), over the past 2 years 3708 cases have been gathered in the surgical community in France and Belgium (Testas and Delaitre, 1991) as shown in Table 9. The results are very similar to ours (Table 1). Similar results have been reported from other European countries (Cuschieri et al, 1991; Troidl et al, 1991), the USA (Berci, 1990; Reddick and Olsen, 1990; Reddick et al, 1991; Zucker et al, 1991) and Australia (Hardy, 1991). This is rightly called a revolution, for even if it is only a part of the trend toward less invasive surgery, it has tremendously accelerated change in the attitude of general surgeons to endoscopic techniques. We must lead this revolution, which is essentially free of a negative side, by: not resurrecting poor operations in traditional surgery simply because they can be performed laparoscopically (Mouret, 1991); avoiding precipitous use of laparoscopic techniques without suitable training; and appropriate analysis of the indications for their use. The group of patients with sclero-atrophic gallbladders, profoundly altered by previous bouts of inflammation, should remain in the hands of the besttrained teams. In the near future we shall see a profusion of publications reporting complications of laparoscopic cholecystectomy, and allowance must be made for a phase of technical maturation of the operators. The stakes are high, for the results of traditional cholecystectomy are excellent. Each new operator should be determined to do at least as well as traditional surgery from the outset by careful patient selection. Two to four years hence the




average results will stabilize at the level of those already obtained by the pioneering teams. Apart from educating surgeons in these techniques, there remains the problem of disseminating information to general practitioners and referring doctors. The length of hospital stay for laparoscopic cholecystectomy is short, but complications can occur soon after discharge. Bleeding or major biliary leaks require a rapid and precise response and justify keeping the patient in or near the endoscopic surgery centre for at least 24 h. Intermediate and late complications occur after a period free from symptoms, and usually do not require urgent treatment. The role of the family doctor is vital so that complications can be detected and treated without delay. Some, such as biliary effusions, can hide behind insidious masks. Other, less invasive, techniques for treating gallstones may perhaps be developed in the near future and we will then be able to fix precise limits on the indications for laparoscopic cholecystectomy (Cuschieri, 1991). Today, however, laparoscopic cholecystectomy is becoming the standard treatment for gallstones in more and more institutions. SUMMARY

Born in secret in 1987 and developed in an atmosphere of scepticism throughout 1988, laparoscopic cholecystectomy triumphed in 1989 and 1990, causing a veritable revolution in the world of general surgery. The 777 consecutive cases that are reported in this chapter reflect the spirit of these various periods. From conservatively restrictive, our indications widened to include 90% of gallstone cases. For us the sclero-atrophic gallgladder still constitutes the greatest endoscopic challenge and should be reserved for the most experienced operators. The rates for mortality (0.1%) and complications (3.3%), which include three common bile duct injuries (0.4%), are comparable to, if not better than, those for traditional cholecystectomy. The quality of recovery is markedly better: near absence of pain, short hospitalization, return to normal physical activity within 10 days, rapid return to work and preservation of the abdominal musculature in sportspeople. These advantages are unavailable to the 5.5% of patients for whom an intraoperative conversion to an open procedure is necessary. Their recovery is that of traditional cholecystectomy, which itself is far from being poor. The large multicentre studies, such as those carried out in France and Belgium recently, reporting 3708 cases, have reached identical conclusions. Laparoscopic cholecystectomy is set to become the gold standard for treatment of gallstones and is the first step towards surgical techniques of the 21st century which will be performed within the musculocutaneous envelope of the intact human body. REFERENCES Berci G (1990) Coelioscopic cholecystectomy. Annuls of Surgery 212(5): 649-650. Cuschieri A (1991) Minimal access surgery and the future of interventional laparoscopy. American Journal of Surgery 161(3): 404-407.




Cuschieri A, Dubois F, Mouiel J et al (1991) The European experience with laparoscopic cholecystectomy. Americun Journal of Surgery 161(3): 385-387. Dubois F, Icard P, Berthelot G et al (1990) Coelioscopic cholecystectomy: preliminary report of 36 cases. Annals of Surgery 191: 271-275. Hardy K (1991) Percutaneous cholecystectomy. Australian and New Zealand Journal of Surgery



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Mouret G (1991) From the first laparoscopic cholecystectomy to the frontiers of laparoscopic surgery. The future prospectives. Digestive Surgery 8(2): 124-125. Ptrissat J, Collet DR & Belliard R (1989) Gallstones: Laparoscopic treatment, intracorporeal lithotripsy followed by cholecystostomy or cholecystectomy-a personal technique. Endoscopy 21 Supp. 1: 373-374. Perissat J, Collet D, Belliard R, Dost C & Bikandou G (1990b) Cholecystectomie par laparoscopie. La technique optratoire. Les resultats des 100 premieres observations. Journal

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Reddick EJ, Olsen DO, Spaw A et al (1991) Safe performance of difficult laparoscopic cholecystectomies. American Journal of Surgery 161(3): 377-381. Testas P & Delaitre B (1991) Chirurgie Digestive par Voie Coelioscopique. Paris: Edition Maloine. Troidl H, Eyrpasch E, Al-Jazini A, Spanberger W & Diehich A (1991) Laparoscopic cholecystectomy in view of medical technology assessment. Digestive Surgery 8(2): 108113. Zucker KA, Bailey RW, Gadacz TR & Imbembo AL (1991) Laparoscopic guided cholecystectomy. American Journal of Surgery 161(6): 36-42; Discussion: 42-44.

Laparoscopic cholecystectomy: an analysis of 777 cases.

Born in secret in 1987 and developed in an atmosphere of scepticism throughout 1988, laparoscopic cholecystectomy triumphed in 1989 and 1990, causing ...
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