The European Experience with Laparoscopic Cholecystectomy Alfred Cuschieri, MD, Phillipe Mouret,
France.
chbl,
FRCS,
MD, Lyon, MD,
Francois Dubois, MD, Paris, FKVWZ,Jean Mouiel, MD, FACS, Nice, Hans Becker, MD, Gerhardt Buess, MD, Tiibingen, Germany, Michael Trede, Germany, Hans Troidl, MD, IGIn-Merheim, Germany
Dundee, Scotland,
France,
Mannheim,
A retrospective survey of 7 European centers involving 20 surgeons who undertook 1,236 laparoscopic cholecystectomies was performed. The procedure was completed in 1,191 patients. Conversion to open eholecystectomy was necessary in 45 patients (3.6%) either because of technical difficulty (n = 33)) the onset of complications (n = 11) , or instrument failure (n = 1) . There were no deaths reported, and the total postoperative complication rate was 20 of 1,203 ( 1.6%), with 9 being serious complications requiring laparotomy. The total incidence of bile duct damage was 4 of 1,203. The median hospital stay was 3 days (range: 1 to 27 days) and the median time to return to full activity after discharge was 11 days (range: 7 to 42 days).
he advent of laparoscopic cholecystectomy has been a significant milestone not only in the treatment of T gallstone disease, but in the evolution of surgical treatment toward the minimal-access approach, the aim of which is intended to minimize the trauma of access without compromising the exposure of the surgical field. Lap aroscopic choleeystectomy originated in Europe, with the first successful case being performed by Phillipe Mouret in i987 (personal communication). Although well established in several centers [I-5], there are different practices and techniques used, and to date it has not been possible to audit both the varying approaches and the overall results of this exciting new surgical advance. A retrospective survey involving seven European centers was thus undertaken to establish the details of the practice in the individual hospitals, the contraindications, and the outcome of the patients treated by laparoscopic cholecystectomy to date. From the Departments of Surgery, Ninewells Hospital and Medical School, Dundee, Scotland (AC); Hopital International de L’Universite de Paris, France (FD); Hopital Saint-Roth, Nice, France (JM); Clinique de la Sauvegarde, Lyon, France (PM); Chirurgischen Universitatsklinik, Ttibingen, Germany (HB, GB); and Chirurgischen Klinik, Mannheim, Germany (MT); and Chirurgischen Klinik, K&r-Merheim, Germany (HT). Requests for reprints should be addressed to Alfred Cuschieri, MD, Department of Surgery, Ninewells Hospital and Medical School, University of Dundee, Dundee DDI 95Y, Scotland.
PATIENT COHORT
Laparoscopic cholecystectomy was attempted by 20 surgeons in 1,236 patients, 952 being women. The age range was 13 to 86 years with a median of 47 years. All patients had symptomatic gallstone disease (biliary colic, chronic cholecystitis, acute cholecystitis). The exact total number of patients with acute inflammation was not available, but from the information received, 29 patients had laparoscopic evidence of recent acute cholecystitis of varying severity at the time of surgery. PRACTICE Contraindications to laparoscopie cholecystectomy: Table I outlines the contraindications listed by the
heads of the various centers involved in the survey. Not all contraindications are agreed on by all the participants; however, all are agreed that severe acute cholecystitis with patchy gangrene or empyema or perforation is a contraindication. Three participants consider that thickening of the gallbladder more than 4 mm is a contraindication, whereas all concur that jaundice, portal hypertension, and pregnancy are absolute contraindications. Patients with gallstone-associated pancreatitis are treated conservatively with delayed or interval laparoscopic cholecystectomy by the majority. Morbid obesity is considered a contraindication when extreme due to inadequate reach by the instruments. Preoperative work-up: The preoperative tests performed in the various centers are shown in Table II. Ultrasound examination is performed by all the surgeons involved in the survey and is regarded as a good guide to the technical difficulty of the operation. Another good index to the feasibility of laparoscopic cholecystectomy is a functioning gallbladder on oral cholecystography, but this is practiced by only 20% of surgeons. Preoperative infusion cholangiography with tomography is performed by the French surgeons as a substitute for perioperative cholangiography with good results and no reports of adverse reactions. Single-dose antibiotic prophylaxis (usually a cephalosporin) is used by 95% of surgeons. Operative practice: The lithotomy position is adopted by the majority of surgeons (Table III). All insert a nasogastric tube during surgery to deflate the stomach, but only 55% catheterize the urinary bladder prior to insufflation of the peritoneal cavity with carbon dioxide. An adjustable camera holder is used by only two surgeons, the rest employing a cameraman for this purpose. Routine perioperative cholangiography is practiced by 25% the rest employing this procedure selectively. Dissection of the cystic pedicle and the gallbladder: Dissection of the cystic pedicle is performed either
with the electrosurgical hook knife (14 surgeons) or the two-handed scissors/graspers technique (6 surgeons).
THE AMERICAN JOURNAL OF SURGERY
VOLUME 161 MARCH 1991
385
CUSCHIERI ET AL
TABLE I Contraindications to LC Listed by the Various Surgeons Condition Severe acute cholecystitislempyema Thickening of the gallbladder (>4 mm) Ductal calculi (failed endoscopic removal) Jaundice Portal hypertension Acute pancreatitis Previous gastrectomy Pregnancy Morbid obesity (extreme)
% Consensus’ 100 15 50 100 100 75 15 100 75
* Based on the number of surgeons from the center(s) in favor of the contraindication.
POSTOPERATIVE OUTCOME
There have been no deaths reported in this survey. The morbidity has been low (Table VI). There were nine major complications requiring laparotomy in the postoperative period (Table VII). The minor complications included six instances of bruising from one of the stab wounds and sepsis of the umbilical stab wound (site of extraction of the gallbladder) in five patients. These infections were late and became manifest 2 to 4 weeks after discharge. The median hospital stay was 3.0 days with a range of 1 to 27 days. Details on time to return to work are available for 560 patients. The median was 11 days with a range of 7 to 42 days. Six patients required readmission for abdominal pain. This settled soon after admission and required no active therapy.
\
TABLE II Preoperative Work-Up % usage Investigation/Procedure Liver function tests Gallbladder ultrasound examination Oral cholecystography Intravenous cholangiography Croup and save Cross match Prophylactic antibiotics
by Surgeons 100 100 20 75 95 0 95
TABLE III Operatlve Practice Procedure Lithotomy position Nasogastric suction Urinary catheterization Camera man Adjustable camera holder Routine perioperative cholangiography Selective perioperative cholangiography
% Usage 75 100 55 90 10 25 75
Ancillary methods employed include pledget swab dissection (two surgeons) or the Berci spatula (two surgeons). The techniques used for the separation of the gallbladder from the liver bed are shown in Table IV. INTRAOPERATIVE OUTCOME
Conversion to open operation was necessary in 45 of 1,236 patients (3.6%) who underwent laparoscopic cholecystectomy. This decision was elective in 33 patients and enforced in 12. The reasons for the enforced conversion are shown in Table V, the major cause being uncontrollable bleeding. Perforation of the gallbladder during dissection from the liver bed was encountered in 194 patients (16%). The average operating time varies from center to center, with a median of 50 minutes (range: 30 to 90 minutes). Surgeons who use perioperative cholangiography routinely incur an average of 20 extra minutes to the duration of the procedure. 386
THE AMERICAN JOURNAL OF SURGERY
LAPAROSCOPIC VERSUS OPEN CHOLECYSTECTOMY Laparoscopic cholecystectomy has been established in four centers over more than 12 months. Collectively, surgeons working in these institutions now treat 97% of their patients with gallstone disease by the laparoscopic approach. In the other three centers, laparoscopic cholecystectomy has been established between 6 to 12 months. Currently in these institutions, 69% of patients are treated by laparoscopic cholecystectomy and the remainder by open cholecystectomy. COMMENTS Some caution is needed with the interpretation of the results of this survey, since the study was retrospective and therefore the data were not complete and possibly subject to the effects of uncontrolled variables. Nonetha less, the message is clear: laparoscopic cholecystectomy is an eminently safe procedure when performed by trained surgeons. It curtails drastically the convalescence period of the patient and is followed by a rapid return to full activity which far exceeds that experienced by patients after open cholecystectomy. The cost implications to insurers (irrespective of its nature) and to the earning capacity of the individual patient are obvious. For the Dundee population included in the study, the cost-saving per patient (largely due to reduced hospital stay) is f900. Despite differences in dissecting techniques used in laparoscopic surgery, the outcome from the various centers was comparable. There is also a clear trend indicating that the percentage of patients treated by laparoscopic cholecystectomy as opposed to open surgery rises with increasing experience. The conversion rate to open cholecystectomy was small. This, however, must be interpreted with caution because details and extent of selection were not available. Indeed, undue emphasis on this criterion as an index of surgical expertise is likely to be counterproductive to the welfare of the patient, since a change to open operation must not be interpreted as a “failure.” Perhaps the best index of surgical judgment is the ratio of elective to enforced conversions. Familiarity with a given technique is probably the most important factor in ensuring safety and determining a consistently successful outcome. The results of this retrospective study do not sug-
VOLUME 161
MARCH 1991
gest that outcome is influenced by any particular technique. The question concerning the need or otherwise for perioperative cholangiography is important. The French surgeons use preoperative infusion cholangiography to detect ductal calculi and dispense with operative cholangiography in the vast majority of patients undergoing laparoscopic cholecystectomy. Their results are impressive and they do not report any adverse effects. The advantage of this approach is the reduction in the operating time, since a laparoscopic cholangiogram performed through the cystic duct adds an average of 20 minutes to the procedure. Nonetheless, an operative cholangiogram in addition to detecting ductal stones provides an accurate road map of the precise anatomy of the extrahepatic biliary tract and may be useful in guiding the surgeon on the safe point at which the cystic duct can be clipped or ligated. Obviously this issue needs to be resolved by prospective studies. A reasonably accurate assessment of the technical difficulty can be obtained preoperatively by the ultrasound scan of the gallbladder and by means of the oral cholecystogram. Thickening of the gallbladder in excess of 4 mm or a nonfunctioning organ are predictors of a shrunken gallbladder with a shortened cystic pedicle. However, with experience, many of these patients can undergo laparoscopic cholecystectomy, although the procedure will be prolonged. There are certain unresolved problems. Perhaps the most important is extraction of the gallbladder, especially when this is full of stones. Existing techniques are laborious and prone to contamination of the exit wound. A “tulip” gallbladder extractor is currently being evaluated for this purpose in one of the participating centers. Another unresolved issue is the management of ductal calculi discovered at laparoscopic cholecystectomy. If small, and provided the anatomy permits, dilation of the cystic duct with the introduction of the flexible choledochoscope and extraction with Dormia basket is possible in some 20% to 30% of cases. Most centers, however, would opt for postoperative endoscopic papillotomy and stone extraction, unless the common bile duct is dilated or the stones multiple and large, when conversion to open operation with formal bile duct exploration is advisable. Despite these problems, laparoscopic cholecystectomy is well established, and there have been few instances in the history of surgical practice where the benefits of the procedure became so clearly manifest within such a short period of time. This European survey, despite its limitations, has shown just that.
TABLE IV Techniques of Dlssectlon of the Gallbladder Method
usage
Electrosurgical hook knife Scissorslgraspers Pledget swab dissection Berci spatula Laser (Nd-YAG) Hydrodissection
14120 6/20 2120’ 2120’ 5120’ 2120’
* Not routinely used or used on an ancillary basis
TABLE V Reasons for Enforced Converslon to Open Cholecystectomy Complication
n
Uncontrollable bleeding from cystic artery Bile duct injury Rupture empyema Instrument failure
6 2 1 1
1 TABLEVI Postoperatlve Morbldlty Excluding Patlents In Whom an Elective Converslon to Open Cholecystectomy Was Performed (n = 1,203) Complication
n (%)
Total complications Major complications Ecchymosis Late infections Readmissions
20 9 6 5 6
(1.6) (0.7) (0.5) (0.4) (0.5)
TABLE VII Major Postoperatlve Compllcatlons Requlrlng Laparotomy Complication
n
Bleeding Common bile duct injury Biliary peritonitis Sepsis Subcapsular hematoma
This appears to be the definitive paper on this new and evolving technique in 1991. REFERENCES 1. Dubois F, Berthelot G, Levard H. Cholecystectomie par coelioscopie. Presse Med 1989; 18: 980-2. 2. Perissat J, Collet D, Belliard R. Gallstones: laparoscopic treatment-cholecystectomy and lithotripsy. Our own technique. Surg
THE AMERICAN
Endosc 1990; 4: 15-7. 3. Reddick EJ, Olsen DO. Laparoscopic laser cholecystectomy. Surg Endosc 1989; 3: 131-3. 4. Cuschieri A. The laparoscopic revolution. J R Co11Surg Edinb 1990; 34: 295. 5. Dubois F, Icard P, Berthelot G, Levard H. Coelioscopic cholecystectomy. Ann Surg 1990; 211: 60-3.
JOURNAL
OF SURGERY
VOLUME
161
MARCH
1991
387
France.
chbl,
FRCS,
MD, Lyon, MD,
Francois Dubois, MD, Paris, FKVWZ,Jean Mouiel, MD, FACS, Nice, Hans Becker, MD, Gerhardt Buess, MD, Tiibingen, Germany, Michael Trede, Germany, Hans Troidl, MD, IGIn-Merheim, Germany
Dundee, Scotland,
France,
Mannheim,
A retrospective survey of 7 European centers involving 20 surgeons who undertook 1,236 laparoscopic cholecystectomies was performed. The procedure was completed in 1,191 patients. Conversion to open eholecystectomy was necessary in 45 patients (3.6%) either because of technical difficulty (n = 33)) the onset of complications (n = 11) , or instrument failure (n = 1) . There were no deaths reported, and the total postoperative complication rate was 20 of 1,203 ( 1.6%), with 9 being serious complications requiring laparotomy. The total incidence of bile duct damage was 4 of 1,203. The median hospital stay was 3 days (range: 1 to 27 days) and the median time to return to full activity after discharge was 11 days (range: 7 to 42 days).
he advent of laparoscopic cholecystectomy has been a significant milestone not only in the treatment of T gallstone disease, but in the evolution of surgical treatment toward the minimal-access approach, the aim of which is intended to minimize the trauma of access without compromising the exposure of the surgical field. Lap aroscopic choleeystectomy originated in Europe, with the first successful case being performed by Phillipe Mouret in i987 (personal communication). Although well established in several centers [I-5], there are different practices and techniques used, and to date it has not been possible to audit both the varying approaches and the overall results of this exciting new surgical advance. A retrospective survey involving seven European centers was thus undertaken to establish the details of the practice in the individual hospitals, the contraindications, and the outcome of the patients treated by laparoscopic cholecystectomy to date. From the Departments of Surgery, Ninewells Hospital and Medical School, Dundee, Scotland (AC); Hopital International de L’Universite de Paris, France (FD); Hopital Saint-Roth, Nice, France (JM); Clinique de la Sauvegarde, Lyon, France (PM); Chirurgischen Universitatsklinik, Ttibingen, Germany (HB, GB); and Chirurgischen Klinik, Mannheim, Germany (MT); and Chirurgischen Klinik, K&r-Merheim, Germany (HT). Requests for reprints should be addressed to Alfred Cuschieri, MD, Department of Surgery, Ninewells Hospital and Medical School, University of Dundee, Dundee DDI 95Y, Scotland.
PATIENT COHORT
Laparoscopic cholecystectomy was attempted by 20 surgeons in 1,236 patients, 952 being women. The age range was 13 to 86 years with a median of 47 years. All patients had symptomatic gallstone disease (biliary colic, chronic cholecystitis, acute cholecystitis). The exact total number of patients with acute inflammation was not available, but from the information received, 29 patients had laparoscopic evidence of recent acute cholecystitis of varying severity at the time of surgery. PRACTICE Contraindications to laparoscopie cholecystectomy: Table I outlines the contraindications listed by the
heads of the various centers involved in the survey. Not all contraindications are agreed on by all the participants; however, all are agreed that severe acute cholecystitis with patchy gangrene or empyema or perforation is a contraindication. Three participants consider that thickening of the gallbladder more than 4 mm is a contraindication, whereas all concur that jaundice, portal hypertension, and pregnancy are absolute contraindications. Patients with gallstone-associated pancreatitis are treated conservatively with delayed or interval laparoscopic cholecystectomy by the majority. Morbid obesity is considered a contraindication when extreme due to inadequate reach by the instruments. Preoperative work-up: The preoperative tests performed in the various centers are shown in Table II. Ultrasound examination is performed by all the surgeons involved in the survey and is regarded as a good guide to the technical difficulty of the operation. Another good index to the feasibility of laparoscopic cholecystectomy is a functioning gallbladder on oral cholecystography, but this is practiced by only 20% of surgeons. Preoperative infusion cholangiography with tomography is performed by the French surgeons as a substitute for perioperative cholangiography with good results and no reports of adverse reactions. Single-dose antibiotic prophylaxis (usually a cephalosporin) is used by 95% of surgeons. Operative practice: The lithotomy position is adopted by the majority of surgeons (Table III). All insert a nasogastric tube during surgery to deflate the stomach, but only 55% catheterize the urinary bladder prior to insufflation of the peritoneal cavity with carbon dioxide. An adjustable camera holder is used by only two surgeons, the rest employing a cameraman for this purpose. Routine perioperative cholangiography is practiced by 25% the rest employing this procedure selectively. Dissection of the cystic pedicle and the gallbladder: Dissection of the cystic pedicle is performed either
with the electrosurgical hook knife (14 surgeons) or the two-handed scissors/graspers technique (6 surgeons).
THE AMERICAN JOURNAL OF SURGERY
VOLUME 161 MARCH 1991
385
CUSCHIERI ET AL
TABLE I Contraindications to LC Listed by the Various Surgeons Condition Severe acute cholecystitislempyema Thickening of the gallbladder (>4 mm) Ductal calculi (failed endoscopic removal) Jaundice Portal hypertension Acute pancreatitis Previous gastrectomy Pregnancy Morbid obesity (extreme)
% Consensus’ 100 15 50 100 100 75 15 100 75
* Based on the number of surgeons from the center(s) in favor of the contraindication.
POSTOPERATIVE OUTCOME
There have been no deaths reported in this survey. The morbidity has been low (Table VI). There were nine major complications requiring laparotomy in the postoperative period (Table VII). The minor complications included six instances of bruising from one of the stab wounds and sepsis of the umbilical stab wound (site of extraction of the gallbladder) in five patients. These infections were late and became manifest 2 to 4 weeks after discharge. The median hospital stay was 3.0 days with a range of 1 to 27 days. Details on time to return to work are available for 560 patients. The median was 11 days with a range of 7 to 42 days. Six patients required readmission for abdominal pain. This settled soon after admission and required no active therapy.
\
TABLE II Preoperative Work-Up % usage Investigation/Procedure Liver function tests Gallbladder ultrasound examination Oral cholecystography Intravenous cholangiography Croup and save Cross match Prophylactic antibiotics
by Surgeons 100 100 20 75 95 0 95
TABLE III Operatlve Practice Procedure Lithotomy position Nasogastric suction Urinary catheterization Camera man Adjustable camera holder Routine perioperative cholangiography Selective perioperative cholangiography
% Usage 75 100 55 90 10 25 75
Ancillary methods employed include pledget swab dissection (two surgeons) or the Berci spatula (two surgeons). The techniques used for the separation of the gallbladder from the liver bed are shown in Table IV. INTRAOPERATIVE OUTCOME
Conversion to open operation was necessary in 45 of 1,236 patients (3.6%) who underwent laparoscopic cholecystectomy. This decision was elective in 33 patients and enforced in 12. The reasons for the enforced conversion are shown in Table V, the major cause being uncontrollable bleeding. Perforation of the gallbladder during dissection from the liver bed was encountered in 194 patients (16%). The average operating time varies from center to center, with a median of 50 minutes (range: 30 to 90 minutes). Surgeons who use perioperative cholangiography routinely incur an average of 20 extra minutes to the duration of the procedure. 386
THE AMERICAN JOURNAL OF SURGERY
LAPAROSCOPIC VERSUS OPEN CHOLECYSTECTOMY Laparoscopic cholecystectomy has been established in four centers over more than 12 months. Collectively, surgeons working in these institutions now treat 97% of their patients with gallstone disease by the laparoscopic approach. In the other three centers, laparoscopic cholecystectomy has been established between 6 to 12 months. Currently in these institutions, 69% of patients are treated by laparoscopic cholecystectomy and the remainder by open cholecystectomy. COMMENTS Some caution is needed with the interpretation of the results of this survey, since the study was retrospective and therefore the data were not complete and possibly subject to the effects of uncontrolled variables. Nonetha less, the message is clear: laparoscopic cholecystectomy is an eminently safe procedure when performed by trained surgeons. It curtails drastically the convalescence period of the patient and is followed by a rapid return to full activity which far exceeds that experienced by patients after open cholecystectomy. The cost implications to insurers (irrespective of its nature) and to the earning capacity of the individual patient are obvious. For the Dundee population included in the study, the cost-saving per patient (largely due to reduced hospital stay) is f900. Despite differences in dissecting techniques used in laparoscopic surgery, the outcome from the various centers was comparable. There is also a clear trend indicating that the percentage of patients treated by laparoscopic cholecystectomy as opposed to open surgery rises with increasing experience. The conversion rate to open cholecystectomy was small. This, however, must be interpreted with caution because details and extent of selection were not available. Indeed, undue emphasis on this criterion as an index of surgical expertise is likely to be counterproductive to the welfare of the patient, since a change to open operation must not be interpreted as a “failure.” Perhaps the best index of surgical judgment is the ratio of elective to enforced conversions. Familiarity with a given technique is probably the most important factor in ensuring safety and determining a consistently successful outcome. The results of this retrospective study do not sug-
VOLUME 161
MARCH 1991
gest that outcome is influenced by any particular technique. The question concerning the need or otherwise for perioperative cholangiography is important. The French surgeons use preoperative infusion cholangiography to detect ductal calculi and dispense with operative cholangiography in the vast majority of patients undergoing laparoscopic cholecystectomy. Their results are impressive and they do not report any adverse effects. The advantage of this approach is the reduction in the operating time, since a laparoscopic cholangiogram performed through the cystic duct adds an average of 20 minutes to the procedure. Nonetheless, an operative cholangiogram in addition to detecting ductal stones provides an accurate road map of the precise anatomy of the extrahepatic biliary tract and may be useful in guiding the surgeon on the safe point at which the cystic duct can be clipped or ligated. Obviously this issue needs to be resolved by prospective studies. A reasonably accurate assessment of the technical difficulty can be obtained preoperatively by the ultrasound scan of the gallbladder and by means of the oral cholecystogram. Thickening of the gallbladder in excess of 4 mm or a nonfunctioning organ are predictors of a shrunken gallbladder with a shortened cystic pedicle. However, with experience, many of these patients can undergo laparoscopic cholecystectomy, although the procedure will be prolonged. There are certain unresolved problems. Perhaps the most important is extraction of the gallbladder, especially when this is full of stones. Existing techniques are laborious and prone to contamination of the exit wound. A “tulip” gallbladder extractor is currently being evaluated for this purpose in one of the participating centers. Another unresolved issue is the management of ductal calculi discovered at laparoscopic cholecystectomy. If small, and provided the anatomy permits, dilation of the cystic duct with the introduction of the flexible choledochoscope and extraction with Dormia basket is possible in some 20% to 30% of cases. Most centers, however, would opt for postoperative endoscopic papillotomy and stone extraction, unless the common bile duct is dilated or the stones multiple and large, when conversion to open operation with formal bile duct exploration is advisable. Despite these problems, laparoscopic cholecystectomy is well established, and there have been few instances in the history of surgical practice where the benefits of the procedure became so clearly manifest within such a short period of time. This European survey, despite its limitations, has shown just that.
TABLE IV Techniques of Dlssectlon of the Gallbladder Method
usage
Electrosurgical hook knife Scissorslgraspers Pledget swab dissection Berci spatula Laser (Nd-YAG) Hydrodissection
14120 6/20 2120’ 2120’ 5120’ 2120’
* Not routinely used or used on an ancillary basis
TABLE V Reasons for Enforced Converslon to Open Cholecystectomy Complication
n
Uncontrollable bleeding from cystic artery Bile duct injury Rupture empyema Instrument failure
6 2 1 1
1 TABLEVI Postoperatlve Morbldlty Excluding Patlents In Whom an Elective Converslon to Open Cholecystectomy Was Performed (n = 1,203) Complication
n (%)
Total complications Major complications Ecchymosis Late infections Readmissions
20 9 6 5 6
(1.6) (0.7) (0.5) (0.4) (0.5)
TABLE VII Major Postoperatlve Compllcatlons Requlrlng Laparotomy Complication
n
Bleeding Common bile duct injury Biliary peritonitis Sepsis Subcapsular hematoma
This appears to be the definitive paper on this new and evolving technique in 1991. REFERENCES 1. Dubois F, Berthelot G, Levard H. Cholecystectomie par coelioscopie. Presse Med 1989; 18: 980-2. 2. Perissat J, Collet D, Belliard R. Gallstones: laparoscopic treatment-cholecystectomy and lithotripsy. Our own technique. Surg
THE AMERICAN
Endosc 1990; 4: 15-7. 3. Reddick EJ, Olsen DO. Laparoscopic laser cholecystectomy. Surg Endosc 1989; 3: 131-3. 4. Cuschieri A. The laparoscopic revolution. J R Co11Surg Edinb 1990; 34: 295. 5. Dubois F, Icard P, Berthelot G, Levard H. Coelioscopic cholecystectomy. Ann Surg 1990; 211: 60-3.
JOURNAL
OF SURGERY
VOLUME
161
MARCH
1991
387
