术中胆道造影在腹腔镜胆囊切除术中的应用

目的探讨术中胆道造影（IOC）在腹腔镜胆囊切除术（LC）中的临床应用价值。方法回顾性分析2003年7月至2008年7月行LC病例442例,其中经ICO患者82例,占手术的18.4%。结果成功完成IOC 81例（97.5%）。发现胆总管结石13例（46.0%）,胆囊管结石4例（4.9%）,胆囊管汇入右肝管4例（4.8%）,胆总管远段狭窄3例（3.7%）,术中胆总管损伤1例（1.2%）。结论 LC中IOC对发现胆管结石的残留、及时发现胆管损伤、明确胆管解剖及变异均有帮助,值得在基层医院推广。     

Pre-operative endoscopic ultrasonography can optimise the management of patients undergoing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocholithiasis: a prospective study

BACKGROUND: Pre-operative endosonography has been proposed as a cost-effective procedure in the management of patients who undergo laparoscopic cholecystectomy having an intermediate risk of common bile duct stones. We prospectively evaluated the impact of pre-operative endosonography on the management of patients facing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocolithiasis. METHODS: Among 587 consecutive patients scheduled for laparoscopic cholecystectomy, 47 (8%) patients having one or more abnormal liver function tests but a normal appearance of common bile duct at abdominal ultrasound, underwent pre-operative endosonography. In patients with endosonography-detected common bile duct stones, a pre-operative endoscopic retrograde cholangiography was performed, or an intra-operative endoscopic retrograde cholangiography was scheduled. In all endosonography-negative patients, an intra-operative trans-cystic cholangiography was performed. RESULTS: Endosonography detected common bile duct stones in nine patients (19%) but only in five of them stones were radiologically confirmed (PPV 0.55). Endosonography-detected stones were confirmed in four of four (100%) patients in whom cholangiography was performed within 1 week, but only in one of five (20%) patients in whom radiology was further delayed (P < 0.05). In three of four cases (75%), stones detected at endosonography but not confirmed at X-rays, were smaller than 2.0 mm. Among 38 patients with negative endosonography, common bile duct stones were found in two patients (NPV 0.95), whereas unplanned endoscopic stone extraction was needed only in one patient (NPV 0.97). CONCLUSIONS: Pre-operative endosonography can spare unnecessary pre-operative endoscopic retrograde cholangiography as well as inappropriate scheduling of intra-operative endoscopic retrograde cholangiography in patients undergoing laparoscopic cholecystectomy with abnormal liver function tests. To maximise the impact of endosonography on the management of these patients, the procedure should be performed immediately before laparoscopic cholecystectomy.     

Imaging of the common bile duct in patients undergoing laparoscopic cholecystectomy.

Options for managing the common bile duct during laparoscopic cholecystectomy include routine peroperative cholangiography and selected preoperative endoscopic retrograde cholangiopancreatography (ERCP). The use of these methods was reviewed in 350 patients with symptomatic gall stones referred for laparoscopic cholecystectomy. Unit A (n = 114) performed routine cystic duct cholangiography but undertook preoperative ERCP in patients at very high risk of duct stones only; unit B (n = 236) performed selected preoperative ERCP on the basis of known risk factors for duct stones. The detection rate for common bile duct stones was similar for units A and B (16% v 20%). In unit A, five of seven patients who had preoperative ERCP had duct stones. Operative cholangiography was technically successful in 90% of patients and duct stones were confidently identified in 13, one of whom went on to immediate open duct exploration. Postoperative ERCP identified duct stones in only four patients, indicating spontaneous passage in eight. In unit B, preoperative ERCP was undertaken in 76 of 236 (32%) patients and duct stones were identified in 47 (20%). Duct clearance was successful in 42 (18%) but failed in five (2%), necessitating elective open duct exploration. Both protocols for imaging the common bile duct worked well and yielded satisfactory short term results.     

Echo-endoscopy versus endoscopic retrograde cholangiography for the diagnosis of choledocholithiasis: the influence of the size of the stone and diameter of the common bile duct

BACKGROUND: Endoscopic retrograde cholangiography is highly accurate in diagnosing choledocholithiasis, but it is the most invasive of the available methods. Endoscopic ultrasonography is a very accurate test for the diagnosis of choledocholithiasis with a risk of complications similar to that of upper gastrointestinal endoscopy. AIM: To compare the accuracy of endoscopic ultrasonography and endoscopic retrograde cholangiography in the diagnosis of common bile duct stones before laparoscopic cholecystectomy and to analyze endoscopic ultrasound results according to stone size and common bile duct diameter. PATIENTS AND METHODS: Two hundred and fifteen patients with symptomatic gallstones were admitted for laparoscopic cholecystectomy. Sixty-eight of them (31.7%) had a dilated common bile duct and/or hepatic biochemical parameter abnormalities. They were submitted to endoscopic ultrasonography and endoscopic retrograde cholangiography. Sphincterotomy and sweeping of the common bile duct were performed if endoscopic ultrasonography or endoscopic retrograde cholangiography were considered positive for choledocholithiasis. After sphincterotomy and common bile duct clearance the largest stone was retrieved for measurement. Endoscopic or surgical explorations of the common bile duct were considered the gold-standard methods for the diagnosis of choledocholithiasis. RESULTS: All 68 patients were submitted to laparoscopic cholecystectomy with intraoperative cholangiography with confirmation of the presence of gallstones. Endoscopic ultrasonography was a more sensitivity test than endoscopic retrograde cholangiography (97% vs. 67%) for the detection of choledocholithiasis. When stones >4.0 mm were analyzed, endoscopic ultrasonography and endoscopic retrograde cholangiography presented similar results (96% vs. 90%). Neither the size of the stone nor the common bile duct diameter had influence on endoscopic ultrasonographic performance. CONCLUSIONS: For a group of patients with an intermediate or moderate risk with respect to the likelihood of having common bile duct stones, endoscopic ultrasonography is a better test for the diagnosis of choledocholithiasis when compared to endoscopic retrograde cholangiography mainly for small-sized calculi.     

腹腔镜下胆道造影术

为探讨腹腔镜下胆道造影的方法和价值，对６００例胆囊结石并慢性或急性胆囊炎（其中４例伴阻塞性黄疸，６例为胆源性胰腺炎）病人行无选择性腹腔镜胆囊切除和常规术中经胆囊管插管胆道造影术。５６８例（９４．７％）完成了术中胆道造影。术中造影发现胆总管病变４２例，其中３２例为术前未曾检查出的胆管异常。全组共发生胆管损伤３例（０．５％）。表明腹腔镜下经胆囊管插管胆道造影成功率高，术中胆道造影具提高手术质量和防止或减少胆管损伤的作用。     

Introduction of a "Safety Zone" for the Safety of Laparoscopic Cholecystectomy

Anatomic variations of the biliary tract were found in 18 cases of 600 patients (3.0%) undergoing laparoscopic cholecystectomy. All bile duct anomalies were confirmed preoperatively by endoscopic retrograde cholangiography. In every case, the cystic duct and cystic artery were exposed in a "safety zone" near the gallbladder neck in Calot's triangle. Laparoscopic cholecystectomy was successfully performed on all 18 cases. Intraoperative cholangiography clearly demonstrated the anatomic variations in all cases, unequivocally identified the cystic duct, and confirmed the absence of bile duct injury. Preoperative endoscopic retrograde cholangiography and intraoperative cholangiography, which have been performed routinely in all patients, improve the safety of laparoscopic cholecystectomy. Moreover, the observance of the essential rule of "keep operating in the safety zone" protects against inadvertent complications, especially against bile duct injury during laparoscopic cholecystectomy. Laparoscopic cholecystectomy was thus successfully performed on all 600 cases in the present series, except for three cases, which were converted to open surgery (conversion rates, 0.5%), because of pin-hole bleeding on the portal vein in our first case of 600, and severe adhesion in two (46th and 302nd) cases.     

Diagnostic workup before laparoscopic cholecystectomy--which diagnostic tools should be used?

BACKGROUND/AIMS: A prerequisite for successful laparoscopic cholecystectomy is the exclusion of potential risks such as cholangiolithiasis, anatomical malformations or diseases of the stomach. As there is no general agreement regarding the appropriate preoperative diagnostic workup, we compared different diagnostic methods as to their value in detecting unknown accompanying diseases and complications. METHODOLOGY: Between 9/90 and 8/93, we performed 850 laparoscopic cholecystectomies. The first 700 were included in this study. A prospective comparison was carried out of the diagnostic accuracy of history, physical examination, laboratory tests, upper gastrointestinal endoscopy or barium meal, i.v. cholangiography and abdominal ultrasound. RESULTS: Measurement of the diameter of the common bile duct was found to be a good noninvasive method for diagnosing common bile duct stones (sensitivity 80%, specificity 99%). In combination with the history and the laboratory tests the sensitivity could be improved to 99%. The sensitivity of i.v. cholangiography in detecting common bile duct stones was 80%, the specificity 99.3%. 646/700 patients underwent preoperative endoscopy/barium meal. In 53 (8.2%) patients pathological findings were found, but only in 4 cases (0.6%) they influenced the indication for laparoscopic cholecystectomy. In 1 patient an advanced gastric cancer was diagnosed 6 months after laparoscopic cholecystectomy, the preoperative barium meal did not show any pathological findings. CONCLUSIONS: The results show that routine ultrasonography in combination with history and laboratory tests prior to laparoscopic cholecystectomy can be recommended for detecting common bile duct stones. In patients with 1 or more pathologic finding endoscopic retrograde cholangiopancreatography should be performed preoperatively. A gastroscopy should be done in patients with nonspecific upper abdominal pain, history of peptic ulcer disease and persisting pain after laparoscopic cholecystectomy.     

Three-dimensional demonstration of cystic duct by helical CT scanning

BACKGROUND/AIMS: We evaluated the usefulness of helical CT scanning with drip-infusion cholangiography for the delineation of choleductal anatomy in preparation for laparoscopic cholecystectomy. METHODOLOGY: One hundred and five cases underwent laparoscopic cholecystectomy for cholecystolithiasis in our department from March 1993 to July 1998. Endoscopic retrograde cholangiography was carried out in 58 cases and helical CT scanning with drip-infusion cholangiography, including, three-dimensional CT in 31 cases. We, retrospectively, investigated three-dimensional helical CT scanning with drip-infusion cholangiography in the point of three-dimensional demonstration of cystic duct anatomy and try to classify the findings. RESULTS: Three-dimensional helical CT scanning with drip-infusion cholangiography visualized three-dimensional anatomy of the cystic duct clearly. For the detection of the biliary disease such as stones and polyps, however, endoscopic retrograde cholangiography is superior (sensitivity; 89.7%) to two-dimensional helical CT scanning with drip-infusion cholangiography (sensitivity; 64.5%) and three-dimensional helical CT scanning with drip-infusion cholangiography (sensitivity; 22.6%) except for large lesions. We have classified the three dimensional helical CT scanning with drip-infusion cholangiography findings in three types. CONCLUSIONS: Three-dimensional helical CT scanning with drip-infusion cholangiography is not only less invasive but also more useful for the delineation of three-dimensional anatomy of the bile duct.     

Single-step treatment of gallbladder and bile duct stones: a combined endoscopic-laparoscopic technique

BACKGROUND: The introduction of laparoscopic cholecystectomy has given rise to a debate as to whether endoscopic retrograde cholangiopancreatography (ERCP) should be performed before or after cholecystectomy in patients with bile duct stones. METHODS: This study evaluated the efficacy of treatment of cholecystocholedocholithiasis in a single step by performing ERCP during surgery in 52 patients (35 women, 17 men; mean age 57.0 years; age range 20 to 89 years). Laparoscopic intraoperative cholangiography via the cystic duct was carried out to confirm the presence of duct stones. A soft-tipped guidewire was passed through the cystic duct and papilla into the duodenum. A papillotome was inserted endoscopically over the guidewire. Endoscopic sphincterectomy was performed and the stones removed with balloon and basket catheters. RESULTS: Endoscopic stone removal was successful in 94% of cases without complications related to ERCP or surgery. Although operative time was lengthened by about 20 minutes, the hospital stay was as short and equal to that for simple laparoscopic cholecystectomy (3 days on average). CONCLUSIONS: The single-step combined endoscopic-laparoscopic technique is safe and effective for treatment of patients with gallbladder and bile duct stones.     

Double cystic duct detected by endoscopic retrograde cholangiopancreatography and confirmed by intraoperative cholangiography in laparoscopic cholecystectomy: a case report

A case of double cystic duct with cholecystolithiasis detected by preoperative endoscopic retrograde cholangiopancreatography and confirmed by intraoperative cholangiography which was treated successfully by laparoscopic surgery is reported. The patient was a 74-year-old woman who complained of abdominal pain in the right upper quadrant. On admission, ultrasonography revealed hyperechoic areas accompanied by obscure acoustic shadows in the gallbladder. Preoperative endoscopic retrograde cholangiopancreatography showed 2 cystic ducts; 1 branched from the common bile duct and the other from the right hepatic duct. After a diagnosis of double cystic ducts, we chose laparoscopic cholecystectomy. Intraoperative cholangiography via 1 of the cystic ducts revealed the presence of the other. We were able to perform laparoscopic cholecystectomy without any complications and the postoperative course was uneventful. This case suggests that preoperative endoscopic retrograde cholangiopancreatography and intraoperative cholangiography is required to avoid complications during laparoscopic cholecystectomy.     

选择性术中胆道造影在腹腔镜胆囊切除术中的应用价值

目的探讨选择性术中胆道造影（PTC）在腹腔镜胆囊切除术（LC）中的应用价值。方法回顾分析35例行LC的患者在术中经胆囊管插管进行胆管造影的结果。结果 35例LC术中胆管造影均成功,术中发现胆总管结石4例,行腹腔镜胆道探查、T型管引流术。结论 LC术中胆管造影操作方便可行,显影清晰,成功率高,能发现术前未能发现的胆总管结石有效的降低胆管残石率,通过造影还可以排除胆道结石,避免阴性探查,减少患者痛苦,在复杂胆囊切除术中可帮助辨别解剖关系、发现解剖变异,避免术中胆管损伤,提高了LC手术的质量和安全性。     

Comparison of laparoscopic ultrasound and cholangiography during laparoscopic cholecystectomies. Results of a prospective study

AIM: Prospective evaluation of the results of laparoscopic ultrasound and cholangiography to investigate choledocholithiasis and detect variations in biliary anatomy during laparoscopic cholecystectomies. METHODS: The biliary trees of 600 patients who underwent laparoscopic cholecystectomy were routinely explored by laparoscopic ultrasound and cholangiography. RESULTS: Laparoscopic ultrasound was performed in all 600 cases. Cholangiography was performed in 498 (83%). Laparoscopic ultrasound required less time than cholangiography: 10.2 minutes versus 17.9 minutes (P=0.0001). Common bile duct stones were detected intraoperatively in 40 cases (7%). Both methods were equally effective. The sensitivity of laparoscopic ultrasound was 80% and its specificity 99%. For cholangiography these values were 75% and 98% respectively. For laparoscopic ultrasound, false positives and false negatives were noted in the first 45 cases of individual trainees. Nevertheless, cholangiography showed 30 anatomical anomalies and laparoscopic ultrasound only 15. CONCLUSION: Laparoscopic ultrasound can be performed rapidly and in all cases. Results are comparable to cholangiography in the detection of common duct stones. Individual training is necessary to optimize efficacy. Anatomical anomalies are often missed.     

Biliary navigation surgery using endoscopic nasobiliary drainage tube for the prevention of bile duct injury in laparoscopic cholecystectomy

Bile duct injury is the most troublesome complication in laparoscopic cholecystectomy (LC). The identification of the anatomical relationship between the cystic duct and common bile duct is one of the most important points for the safe LC. Therefore, we introduced a biliary navigation surgery using endoscopic nasobiliary drainage (ENBD) tube to avoid bile duct injury during LC. The benefit of intraoperative cholangiography using an ENBD tube is that the identification of the anatomical relationship between the cystic duct and common bile duct can be confirmed by using intraoperative cholangiography through the ENBD tube. We consider that ENBD tube is useful for identifying the biliary tract by repeated intraoperative cholangiography and, thus, for preventing injury to the bile duct in LC.     

Management of unsuspected common bile duct stones found during laparoscopic cholecystectomy by means of transcystic catheter placement and papillary dilation

BACKGROUND: The optimal treatment strategy for treatment of bile duct stones first diagnosed during laparoscopic cholecystectomy has not been established. We prospectively treated unsuspected bile duct stones by means of intraoperative placement of a transcystic catheter followed by postoperative pharmacologic papillary dilation or endoscopic papillary balloon dilation. METHODS: In 17 patients with bile duct stones first found at laparoscopic cholecystectomy, a catheter was introduced via the cystic duct into the bile duct. If postoperative cholangiography via a transcystic catheter showed stones 5 mm or less in diameter, glyceryl trinitrate was infused via the catheter into the bile duct. Patients in whom medical dilation was unsuccessful or who had larger stones underwent endoscopic papillary balloon dilation. RESULTS: Stone diameter measured 3 to 11 mm (mean 6.4 mm). Postoperative cholangiography revealed spontaneous passage in four patients. After pharmacologic papillary dilation, two of five patients with stones 5 mm or less in diameter had stone clearance. The remaining 11 patients underwent successful endoscopic papillary balloon dilation with stone clearance. In two patients, a guidewire introduced via a transcystic catheter through the papilla facilitated selective biliary cannulation. One early minor complication occurred. All patients remained without symptoms for a mean follow-up of 13 months. CONCLUSION: For unsuspected bile duct stones (usually small ones), this strategy is a simple and effective alternative to laparoscopic bile duct exploration and postoperative sphincterotomy and may minimize early and late complications. Transcystic catheterization ensures access to the bile duct, thereby avoiding endoscopic treatment failures.     

Laparoscopic cholecystectomy and intraoperative endoscopic sphincterotomy in the treatment of cholecysto-choledocholithiasis.

BACKGROUND: A single-stage minimally invasive procedure would be optimal for management of cholecysto-choledocholithiasis. Two alternative strategies are available: management by laparoscopy alone or a combined laparoscopic-endoscopic approach. This study evaluates the results of the latter procedure. METHODS: From June 1993 to September 1997, 1400 patients with symptomatic biliary stone disease were evaluated for laparoscopic cholecystectomy. Intraoperative cholangiography was performed on the basis of a preoperative suspicion of bile duct stones; bile duct stone treatment was by intraoperative endoscopic retrograde sphincterotomy. RESULTS: Intraoperative cholangiography was performed because of a preoperative suspicion of a bile duct abnormality in 141 of 1400 patients (10%) undergoing laparoscopic cholecystectomy because of biliary stone disease. Of those 141 patients, 54 (38.3%) presented with pathologic findings (bile duct stone [52] and papillary stenosis [2]); all 54 underwent intraoperative endoscopic sphincterotomy. Complete clearance of the ductal stones was achieved in 43 patients (82.7%) by intraoperative sphincterotomy, and in 9 patients by an additional postoperative endoscopic procedure. Laparoscopic cholecystectomy was carried out in all cases. There were no conversions to an open operation. Postoperative course in the uncomplicated cases was comparable to that for laparoscopic cholecystectomy alone. The postoperative complication rate was 5.6% and mortality 1.8%. Mean hospital stay was 3.3 days (range 2 to 16). At a mean 38 months follow-up, no complications related to the laparoscopic-endoscopic procedure were observed. CONCLUSION: The intraoperative combined laparoscopic-endoscopic approach seems to be a feasible and effective management of cholecysto-choledocholithiasis, saving patients a subsequent invasive procedure.     

Acute biliary pancreatitis: staging and management

BACKGROUND/AIMS: Acute biliary pancreatitis is a clinical entity with a high morbidity rate (15-50%) and mortality rate (20-35%). Early diagnosis has a primary importance for an appropriate treatment (75% of cases of idiopathic acute pancreatitis are of biliary origin). METHODOLOGY: Diagnosis of acute biliary pancreatitis in 78 patients was based on careful clinical and instrumental assessment: ultrasonography (76.9% of cases) and laboratory tests in 23.1% of cases. In our study we used the Ranson and APACHE II scores and 24 of the cases (30.7%) were classified as severe, while 54 (69.2%) were mild. All patients with severe acute biliary pancreatitis underwent emergency endoscopic retrograde cholangiopancreatography + endoscopic sphincterotomy (within 24-48 hours) followed by laparoscopic cholecystectomy (10 days). Patients with mild acute biliary pancreatitis underwent laparoscopic cholecystectomy associated with intraoperative cholangiography, within 10 days. RESULTS: In 19 patients with severe acute biliary pancreatitis operative endoscopy was curative. Subsequent laparoscopic cholecystectomy provoked subcutaneous emphysema only in one case but did not show any other serious morbidity. In the remaining 5 cases laparotomy was required because of necrosis, with a mortality rate of 60%. In all cases of mild acute biliary pancreatitis, laparoscopic cholecystectomy was successfully performed with a morbidity rate of 7.3%. Common bile duct stones were revealed with intraoperative cholangiography in 31.4% of the mild cases and in 75% of the severe cases. CONCLUSIONS: In conclusion acute biliary pancreatitis treatment is always surgical; in almost all severe cases it is performed with minimally invasive procedures (endoscopic retrograde cholangiopancreatography + endoscopic sphincterotomy with laparoscopic cholecystectomy < or = 10 days) if surgery is carried out within 24-48 hrs, as well in the mild cases (laparoscopic cholecystectomy + intraoperative cholangiography) when surgery is performed within 10 days.     

The case for laparoscopic common bile duct exploration

The modern surgeon's approach to choledocholithiasis depends his or her view of cholangiography. During the early 1990 there was a swing away from cholangiography, which had previously been common practice. This was because of perceptions of difficulty with the technique, the time it took, and perhaps an implied increase in costs because of the time factor. There was no evidence on which to base this decision. This led to a marked upswing in the use of endoscopic retrograde cholangiopancreatography (ERCP). There were a large number of ERCPs with normal results performed prior to laparoscopic cholecystectomy. This paper states the case for intraoperative cholangiography and common bile duct clearance at the time of cholecystectomy. It is hoped that this technique will be adopted so patients can undergo a single procedure to remove their gallstones and common bile duct stones if they exist and to decrease the incidence of normal preoperative ERCPs and the need for a second procedure postoperatively to clear stones if they are found.     

Clinical evaluation of 3D-CT cholangiography for preoperative examination in laparoscopic cholecystectomy

Three-dimensional-computed tomography (3D-CT) cholangiography is a 3D shaded surface display image of the biliary tract obtained by using helical CT after intravenous cholangiography or cholangiography per percutaneous transhepatic cholangio-drainage tube. We investigated whether 3D-CT cholangiography could provide a useful image, for preoperative examination in laparoscopic cholecystectomy. Sixty-five patients with biliary diseases were examined by 3D-CT cholangiography. Helical scanning was performed on a Proceed Accell (GE Medical Systems, Waukesha, WI, USA). Three-dimensional images were created using an independent workstation. A clear image of the common bile duct was obtained for all patients (100%) by 3D-CT cholangiography. The gallbladder was well visualized in 54 (93%) and the cystic duct was shown to be opacified in 55 (95%) of the 58 patients with a gallbladder. Thirty-one patients were diagnosed as having gallstones by 3D-CT cholangiography (sensitivity, 72.1%; specificity, 100%; accuracy, 79.3%), while 43 were diagnosed as having cholecystolithiasis by ultrasonography. The advantages of 3D-CT cholangiography were a low level of invasiveness, easily obtained images compared to those obtained with endoscopic retrograde cholangiography (ERC), good opacification, and provision of a three-dimensional understanding of the biliary system, especially of the cystic duct. When combined with ultrasonography and routine liver function tests, 3D-CT cholangiography was considered very useful for obtaining information before laparoscopic cholecystectomy. It allowed the omission of ERC in many patients who were considered to have no common bile duct stone, by employment of 3D-CT cholangiography. (Received Apr. 22, 1998; accepted Aug. 28, 1998)     

Selective preoperative endoscopic retrograde cholangiography with sphincterotomy avoids bile duct exploration during laparoscopic cholecystectomy.

A policy of preoperative endoscopic retrograde cholangiography (ERC) for suspected bile duct stones was used in 1507 patients considered for laparoscopic cholecystectomy in three district general hospitals. Altogether 306 patients underwent ERC, and bile duct cannulation was achieved in 276 (90%). Bile ducts were cleared by endoscopic sphincterotomy in 128 of 161 patients (79%) with proven duct stones. Laparoscopic cholecystectomy was completed in 1396 patients. Ten laparotomies were necessary for complications of laparoscopic cholecystectomy. The complication rate for endoscopic sphincterotomy/laparoscopic cholecystectomy was 2.7%, with no mortality. Overall, a combined endoscopic/laparoscopic approach succeeded in 1386 patients (92%). Fourteen patients (1%) had retained stones during a median of 14 months (range 1-42) follow up, all of which were removed by ERC/endoscopic sphincterotomy. If a policy of selective ERC before laparoscopic cholecystectomy is used for all patients with symptomatic gall stones, most will avoid an open operation and laparoscopic exploration of the bile duct is not necessary.     

Role of Preoperative Endoscopic Retrograde Cholangiography in Laparoscopic Cholecystectomy

Abstract: An endoscopic retrograde cholangiography (ERC) was performed in 303 patients before laparoscopic cholecystectory. The ERC was successful in 275 patients (90.8%). Common bile duct stones were diagnosed in 9 of 275 patients (3.3%). These had not been suspected on the basis of the clinical and laboratory data or ultrasonography results in 8 of them. An endoscopic papilotomy (EPT) was successful in all 9 patients with choledocholithiasis before laparoscopic cholecystectomy. Anatomical variations, such as origin of the cystic duct from the right or left hepatic duct and an accessory bile duct, were detected in 6 patients (2.2%). Preoperative ERC proved useful in determining the biliary anatomy or detecting unsuspected stones. (Dig Endosc 1994; 6 : 24–27)