Aust. N.Z.J . Surg. 1992.62.150
COMMENTS LAPAROSCOPIC CHOLECYSTECTOMY: AN AUSTRALIAN VIEW P. D. NO-ITLE Department of Surgery, AIfred Hospital, Melbourne, Victoria Lapmcopic cholecystectomy has rapidly overtaken open cholecystectomy as the standard procedure for the treatment of gallstone disease. At least 80% of patients, more as experience increases, can be managed in this way.’ The only absolute surgical contraindication to the procedure is a stone within the common duct that cannot be removed endoscopically. Relative contra-indications include acute cholecystitis, previous upper abdominal surgery and pregnancy. Although the procedure can be performed in all these circumstances, care must be taken. The two great debates surrounding the procedure concern the routine use of operative cholangiography and the training of endoscopic surgeons. Berci has stated that routine operative cholangiography is essential in this procedure, mainly because it is required to define anatomy and not just to detect unsuspected stones.’ While it is quite valid to use operative cholangiography to detect unsuspected calculi, there are limitations to exploration of the bile duct during laparoscopic cholecystectomy. Small stones may be removed using a stonebasket introduced through a fine choledochoscope inserted into the cystic duct or even washed through into the duodenum. Laparoscopic exploration of the duct is limited at present but should increase in future. What is essential, is careful preoperative assessment of the patient to be certain that the common duct is clear of stones. In order to do this, preoperative endoscopic retrograde cholangiopancreatography (ERCP) can be used where stones are suspected and if stones are present, they can be dealt with at that time. What if stones are found on cholangiography and cannot be removed intra-operatively? Does the surgeon convert the procedure to an open operation or leave them to be removed at ERCP? To leave the patient with a known duct stone leaves the patient at risk of developing a blown cystic duct stump, if the stone should lodge in the sphincter and also to the possibility of an open operation requiring a second anaesthetic if the stone cannot be removed at ERCP. A careful pre-operative search for stones overcomes all these problems. To use operative cholangiography to define
anatomy is inappropriate. Anatomy must be defined by clear surgical dissection of Calot’s triangle and also the space between the cystic artery and liver to produce two triangles or windows before any c l i p ping or division of vascular or ductal structures is performed. If this is done, the anatomy is always clearly displayed before any duct is clipped and before an operative cholangiogram is performed if that is the choice of the surgeon. What training do general surgeons require before they undertake laparoscopic cholecystectomy? New skills that are required by general surgeons are the techniques required to safely perform laparoscopy and surgical procedures in a two dimensional plane. No general surgeon in Australia who wishes to continue performing biliary surgery should be denied access to this procedure because no patient should be denied the clear benefits of having their cholecystectomy performed laparoscopically. In fact there are enough surgeons performing this procedure in Australia at present to question the justification of open cholecystectomy in uncomplicated gallstone disease. Surgery has always been taught at the operating table and any course in this procedure must include a training component where a surgeon is assisted by those under instruction. Animal laboratories will never take the place of this time honoured technique of teaching surgery and should not do so in this instance. In conclusion, we are on the threshold of an exciting new era in surgery and we must be prepared to adapt our surgical thinking to both the advantages and disadvantages of new techniques which are being put forward on an almost daily basis. All young surgeons will be trained in laparoscopic cholecystectomy and we must ensure that surgeons who are in established practice also learn the procedure so that the present high standard of surgery in Australia is maintained. References 1. NOTTLE P. D. (1991) Laparoscopic cholecystectomy. Aust. Med, J. 1546) 421. 2. BERCI G. (1991) Laparoscopic cholecystectomy viewed from the USA. Aust. N.Z. 1. Sure. 61(4) 249-50.
COMMENTS LAPAROSCOPIC CHOLECYSTECTOMY: AN AUSTRALIAN VIEW P. D. NO-ITLE Department of Surgery, AIfred Hospital, Melbourne, Victoria Lapmcopic cholecystectomy has rapidly overtaken open cholecystectomy as the standard procedure for the treatment of gallstone disease. At least 80% of patients, more as experience increases, can be managed in this way.’ The only absolute surgical contraindication to the procedure is a stone within the common duct that cannot be removed endoscopically. Relative contra-indications include acute cholecystitis, previous upper abdominal surgery and pregnancy. Although the procedure can be performed in all these circumstances, care must be taken. The two great debates surrounding the procedure concern the routine use of operative cholangiography and the training of endoscopic surgeons. Berci has stated that routine operative cholangiography is essential in this procedure, mainly because it is required to define anatomy and not just to detect unsuspected stones.’ While it is quite valid to use operative cholangiography to detect unsuspected calculi, there are limitations to exploration of the bile duct during laparoscopic cholecystectomy. Small stones may be removed using a stonebasket introduced through a fine choledochoscope inserted into the cystic duct or even washed through into the duodenum. Laparoscopic exploration of the duct is limited at present but should increase in future. What is essential, is careful preoperative assessment of the patient to be certain that the common duct is clear of stones. In order to do this, preoperative endoscopic retrograde cholangiopancreatography (ERCP) can be used where stones are suspected and if stones are present, they can be dealt with at that time. What if stones are found on cholangiography and cannot be removed intra-operatively? Does the surgeon convert the procedure to an open operation or leave them to be removed at ERCP? To leave the patient with a known duct stone leaves the patient at risk of developing a blown cystic duct stump, if the stone should lodge in the sphincter and also to the possibility of an open operation requiring a second anaesthetic if the stone cannot be removed at ERCP. A careful pre-operative search for stones overcomes all these problems. To use operative cholangiography to define
anatomy is inappropriate. Anatomy must be defined by clear surgical dissection of Calot’s triangle and also the space between the cystic artery and liver to produce two triangles or windows before any c l i p ping or division of vascular or ductal structures is performed. If this is done, the anatomy is always clearly displayed before any duct is clipped and before an operative cholangiogram is performed if that is the choice of the surgeon. What training do general surgeons require before they undertake laparoscopic cholecystectomy? New skills that are required by general surgeons are the techniques required to safely perform laparoscopy and surgical procedures in a two dimensional plane. No general surgeon in Australia who wishes to continue performing biliary surgery should be denied access to this procedure because no patient should be denied the clear benefits of having their cholecystectomy performed laparoscopically. In fact there are enough surgeons performing this procedure in Australia at present to question the justification of open cholecystectomy in uncomplicated gallstone disease. Surgery has always been taught at the operating table and any course in this procedure must include a training component where a surgeon is assisted by those under instruction. Animal laboratories will never take the place of this time honoured technique of teaching surgery and should not do so in this instance. In conclusion, we are on the threshold of an exciting new era in surgery and we must be prepared to adapt our surgical thinking to both the advantages and disadvantages of new techniques which are being put forward on an almost daily basis. All young surgeons will be trained in laparoscopic cholecystectomy and we must ensure that surgeons who are in established practice also learn the procedure so that the present high standard of surgery in Australia is maintained. References 1. NOTTLE P. D. (1991) Laparoscopic cholecystectomy. Aust. Med, J. 1546) 421. 2. BERCI G. (1991) Laparoscopic cholecystectomy viewed from the USA. Aust. N.Z. 1. Sure. 61(4) 249-50.
