What is the ideal treatment for gallbladder stones? Secondly, the effect is the basic condition. If the effect is maintained for too short a time, the value of the treatment cannot be maintained; finally, there is no interference or micro-interference in the near and far-term internal environment of the human body, i.e., it should be “minimally invasive”. The logic of bile cutting The historical roots of the logic of bile cutting go back to the pre-Langenbuch era. Due to poor diagnostic techniques, gallbladder stones could only be detected when they caused complications, which were often fatal and had a very high mortality rate. Without efficient antimicrobial drugs and without the technology and conditions to deal with secondary internal environmental disturbances, removal of the diseased gallbladder was apparently the only means that might effectively save the patient’s life. It was in this context that Dr. Langenbuch in Germany invented cholecystectomy, which was epoch-making in the history of surgery. Although death still occurred under the conditions of the time, it was clearly a huge improvement over the old practice of sitting on the sidelines, and later, as overall medicine continued to advance, the procedure was refined and its results improved, and it naturally became the “gold standard” for the treatment of gallbladder stones. The logic of treating gallbladder stones at this time was simple: because the gallbladder produced stones, which in turn destroyed the gallbladder and endangered lives, removal was the only option. Later, with the advent of technology, new diagnostic tools, especially B-mode ultrasound instruments, made it possible for doctors to detect stones at or before the onset of clinical symptoms of gallbladder stones. This method of detection offers the possibility of analyzing the epidemiology and natural evolution of gallbladder stone disease because of its accuracy, rapidity, non-invasiveness, simplicity of operation and multiple repetitions. The results of up to 15 years of follow-up found that only 20% of gallbladder stone patients develop symptoms and 80% can be asymptomatic for life. Therefore, the idea that asymptomatic stones do not require treatment has been proposed and is accepted by a very large majority of scholars. However, in the case of symptomatic stones, gallbladder removal is still advocated because there is no proven non-surgical treatment. The logic at this point is that the gallbladder should be removed not only because of the stones in the gallbladder, but because the gallbladder is the “soil” where the stones are produced. This is the “hotbed doctrine” pointed out by the famous scholar Prof. Zhang Baoshan. 2, the error of the logic of cutting gallbladder The logic of cutting gallbladder is based on the following premises: 1) the gallbladder is dispensable or has no value in the short term; 2) the gallbladder must be cut; 3) it is absolutely safe to remove the gallbladder; 4) gallbladder stones are bound to recur after removal. The first one is obviously wrong, humans have not “***” the gallbladder after tens of thousands of years of evolution, which naturally indicates its existence value. With the development of medical science and technology, there is further understanding of the gallbladder as an important digestive organ. In addition to its role in concentrating, contracting and regulating the pressure of the cushioned bile duct, the gallbladder is also a complex organ with chemical and immunological functions. The second rule is only valid when the gallbladder is suspected to be cancerous or has become cancerous, the gallbladder has lost its function, and complications have occurred, so most gallbladders with stones do not have to be cut. Cholecystectomy is not absolutely safe. Injury to the common bile duct is a very serious complication of laparoscopic cholecystectomy, amounting to 1%, and Morgensten et al. reported a mortality rate of 1.8% for cesarean cholecystectomy, all in patients older than 66 years of age. When choledochotomy is necessary, the mortality rate increases threefold. The situation is similar for laparoscopic cholecystectomy. Finally, stone recurrence after stone extraction is not inevitable. It has been shown that the recurrence rate of stones at 15-year follow-up is between 2% and 7% with the new biliary stone extraction method. If, gallbladder stones = gallbladder + stones; then, gallbladder stones – stones = gallbladder. But the logic of the blind gallbladder cutter is: if gallbladder stones = gallbladder + stones, then gallbladder stones – stones = gallbladder stones, in other words, once the gallbladder has stones, even if the stones are removed, the stones are bound to recur. In other words, once the gallbladder has stones, even if the stones are removed, they are bound to recur, unless they are guaranteed never to recur. There is no doubt that this is an extremely wrong viewpoint. Even if one considers a person as a machine and the gallbladder as a component, if something goes wrong, it should be repaired, even though it cannot be replaced, and it should not be left alone. It has been proved that numerous problems can occur after gallbladder removal, such as dyspepsia, duodenal fluid reflux, gastroesophageal reflux, increased incidence of colon cancer, increased incidence of dilated common bile duct and stones, common bile duct injury and postoperative gallbladder syndrome. 3, the logic of gallbladder preservation First of all, the gallbladder is born and received from its parents. This is not just an intuition and belief, the diversity of gallbladder functions has been confirmed by medical science. Secondly, gallbladder preservation surgery, especially the new type of gallbladder preservation invented by Prof. Zhang Baoshan and others, has the advantages of safe surgery, easy operation, reliable efficacy and low recurrence rate, and it has been proved that the recurrence of gallbladder stones is related to the incomplete removal of stones by the old type of gallbladder preservation. Finally, humans have shown unlimited potential to recognize and prevent the formation of gallbladder stones. Regarding stone recurrence, follow-up times and outcomes vary widely, which is related to patient selection, grasp of indications, treatment methods, and post-surgical management. In the face of recurrence, we should ask not only why recurrence, but also why it does not occur, and perhaps the latter is more likely to provide us with ideas and clues to address stone recurrence. Prof. Zhang Shengdao pointed out that “even if the recurrence rate is as high as 50% after biliary preservation, it is still meaningful to have half of the gallbladder preserved”. Therefore, gallbladder preservation and lithotripsy treatment not only can solve practical problems in clinical practice, but also is an indispensable part of future gallstone disease research. 4. True minimally invasive With reference to the criteria listed at the beginning of this article, the new biliary stone extraction method basically satisfies the conditions, except for the uncertainty of long-term effects. The laparoscopic technique used to resect the gallbladder is undoubtedly minimally invasive when viewed from the human body alone, but it is still not truly minimally invasive compared to biliary preservation treatment in terms of physiological integrity and patient psychology. It not only has all the advantages of minimally invasive surgery, but also differs from cholecystectomy in that it preserves the function of the gallbladder, which can treat the disease while keeping the structure and function of the body intact. 5, the timing of gallbladder preservation treatment The history of gallbladder stone genesis and natural evolution tells us that the formation of stones is the result of the joint action of genetics and environment, and its process can be roughly divided into the following consecutive stages: Phase I – genetic phase, i.e. congenital abnormalities of liver bile acid, cholesterol or lipid metabolism; Phase II -chemical phase, the appearance of lithogenic cholesterol supersaturated bile; Phase III -physical phase, the appearance of cholesterol crystals visible under light microscopy, involving nucleation in the gallbladder; Phase IV Phase IV – Growth phase, in which small crystals grow into stones visible to the naked eye; Phase V – Clinical phase, in which clinical symptoms associated with stones appear, including typical symptoms of biliary colic caused by gallbladder jugular or cystic duct obstruction, non-specific symptoms of chronic inflammation of the gallbladder (dyspepsia, bloating and epigastric pain, etc.), and symptoms caused by complications of gallbladder stones symptoms (fever, jaundice, left upper abdominal pain, etc.) caused by complications of gallbladder stones. Based on the above understanding, prevention can be broadly divided into four levels: primary prevention, to prevent stones in people susceptible to gallbladder stones; secondary prevention, to effectively treat asymptomatic gallbladder stones to prevent complications or further stone enlargement; tertiary prevention, to treat patients with symptomatic stones to prevent or delay loss of gallbladder function or prevent complications; and quaternary prevention, to eliminate stones and then prevent after stone elimination to prevent stone regeneration. Secondary prevention, the effective treatment of asymptomatic stones to prevent the development of symptoms or complications, challenges the currently popular view that asymptomatic stones do not require treatment. For a given individual, if it is possible to know if and when symptoms will develop, then they can be left untreated or wait until the problem is imminent. However, this is not the case, as we can only detect stones early by screening, but cannot predict when, where and how they will develop. Before the advent of laparoscopic cholecystectomy technology, caesarean section surgery was, after all, more damaging to the human body and is feared today, so most people advocate treatment only when symptoms appear, with the result that most patients are admitted to the hospital for surgery only when they have obvious clinical symptoms or complications. The advent of the era of minimally invasive surgery, represented by laparoscopic technology, has naturally eased the fear of gallbladder removal, leading more and more patients to undergo gallbladder removal when their symptoms are not severe. On the contrary, encouraged by the advantages of laparoscopic cholecystectomy, a group of “gallbladder cutting professionals” have emerged who ignore the function of gallbladder, as a result, gallbladder becomes more and more cuttable, and more and more early stone carriers have lost their precious gallbladder and become the carriers of gallbladder. As a result, more and more early stone carriers have lost their precious gallbladders and become “gutless heroes”. The best strategy to solve this paradox is minimally invasive gallbladder stone extraction. The symptoms and complications of gallbladder stones are caused by the stones, which can be eliminated without removing the gallbladder. Moreover, the gallbladder functions better in the asymptomatic stage, with high preservation value, low surgical difficulty, relatively young age of the patient, and high safety of the operation. Therefore, for gallbladder stones, our basic proposition is: once detected, deal with them as early as possible; the method is: preserve the gallbladder and remove the stones. Since the purpose of gallbladder preservation is to preserve the function of the gallbladder and let the gallbladder serve the physiological activities of the human body, the principle of gallbladder preservation is to preserve the functional gallbladder. In other words, “if it should be preserved, it should be cut”. This is done by determining whether the gallbladder has good contractile and bile-concentrating function prior to biliary preservation treatment, which can be determined by ultrasound and cholecystography. However, in order to meet the individual needs of the patient, even if the gallbladder is valuable to be preserved, the treatment plan should be provided in conjunction with the patient’s expectation of the long-term effect of biliary therapy: if the patient requires the effect of biliary therapy to be permanent, then removal of the gallbladder is recommended; if the patient wants the gallbladder to serve him/her for a longer period of time, then biliary therapy can be performed first and then prevent the recurrence of stones; once the stones recur, removal of the In case of stone recurrence, it is recommended to remove the gallbladder or to preserve it again, depending on the specific situation of the gallbladder. Therefore, my opinion is that the recurrence of stones should not be the only criterion for gallbladder preservation and removal, but should be combined with the functional status of the gallbladder and the patient’s attitude and expectation for gallbladder preservation treatment.