Gallbladder stones are a common and frequent disease all over the world. There are various treatment methods, such as lithotripsy, lithotripsy, lithotripsy and surgery, but the main treatment method is still surgery. For more than 100 years, gallbladder removal has been regarded as the “gold standard” for the treatment of gallbladder stones, influenced by the “gallbladder hotbed doctrine” of the famous German doctor Langenbuch. However, with the development of minimally invasive surgery such as endoscopic technology and laparoscopic technology, the re-understanding of the causes of gallbladder stones, and the increasing understanding of post-cholecystectomy complications and the physiological function of the gallbladder itself, the call for gallbladder preservation and stone extraction has been increasing. The debate on “bile preservation” or “bile cutting” is also increasing. The gallbladder, as an organ of the human body, has the following five roles: ① storage of bile: bile is stored in the gallbladder, and then discharged from the gallbladder when digestion is needed, so the gallbladder is called the “bile warehouse”.
At the same time, the gallbladder also plays a role in regulating the pressure of the bile duct. ② Concentrated bile: after the liver bile is absorbed by the mucous membrane of the gallbladder, the active ingredients of the bile are stored in the gallbladder and turned into gallbladder bile. ③
Secretory function: The gallbladder mucosa can secrete thick mucus of about 2O ml per day to protect the bile duct mucosa from concentrated bile. ④
Emptying: After eating, the gallbladder contracts and drains the bile in the gallbladder into the duodenum immediately to help digestion and absorption of fat, and while draining the bile, it also drains the bacteria in the bile duct along with the bile. ⑤
Immune function: The gallbladder mucosa has the function of secreting IgA antibodies, whose concentration in the bile is much higher than that in the blood, and therefore is the main organ containing protective antibodies, which is important for the immune defense of the biliary system. Thus, we can see that the gallbladder has an important role in the physiological metabolism, digestion, and immunity of the body and is not an dispensable organ. Thus, the removal of the gallbladder at every turn in patients with gallbladder stones deserves deep thought and concern! The late academician Qiu Fazu, a leading surgeon, made it clear in 2007 that we should pay attention to the function of the gallbladder, play the role of the gallbladder and protect its existence. And the famous surgeon academician Huang Zhiqiang has repeatedly asked rhetorically, “Should the gallbladder be removed in all cases of gallbladder stone disease?” While we remove the gallbladder to relieve the patient of the pain caused by gallbladder stones, we should also think about the pain caused by post-cholecystectomy complications. So let’s take a look at the disadvantages after gallbladder removal. Bloating and diarrhea, indigestion; bile and intestinal fluid reflux, stomach pain and bloating; increased incidence of colon cancer; bile duct injury; increased incidence of common bile duct stones; post-cholecystectomy syndrome; increased incidence of common bile duct stones. Therefore, Professor Zhang Baoshan, the originator of Chinese choledochoscopy, took the lead in leading some hospitals in the country to engage in research and exploration of endoscopic minimally invasive bile stone extraction of gallbladder stones, and summarized a set of experience and methods of endoscopic bile stone extraction in China, with a recurrence rate of 2%-7% in a 15-year follow-up. This technique is less invasive, easy to operate, does not require dissection of the gallbladder triangle, is performed in the gallbladder cavity, it is impossible to injure the common bile duct and organs around the gallbladder, and the complication rate is lower than that of laparoscopic resection, which is very popular among patients. Of course, not all gallbladder stones can be removed with biliary preservation. This requires us to strictly select patients who are suitable for biliary stone extraction. Patients for gallbladder stone extraction should meet the following conditions;
(1) Normal gallbladder function is a prerequisite for biliary lithotripsy, which can be reflected by the absence of significant thickening of the gallbladder wall and ultrasound measurement of gallbladder contraction area >30% after fasting and fatty meal. ②Asymptomatic or with mild symptoms and a short history. ③Single gallbladder stones or multiple gallbladder stones with low number and small size. ④In case of combined common bile duct stones, EST can be performed first before biliary stone extraction. The stone retrieval rate of biliary stone extraction is 100%, and the combined application of laparoscopy and choledochoscopy with extracorporeal direct vision minimally invasive biliary stone extraction has the following advantages: ①Small trauma, safe and reliable, few complications. It avoids intraoperative damage to the hepatobiliary duct, blood vessels and the gastrointestinal tract; ②Simple operation, easy to learn and promote; ③Maintains the integrity of the bile duct and the function of the gallbladder. Avoid complications after cholecystectomy. Such as steatorrhea, bile reflux gastritis, esophagitis, and postoperative biliary tract dysfunction. ④Effectively avoid complications such as postoperative bile leakage, bleeding and accumulation of fluid and blood in the abdominal cavity; ⑤ Possibly reduce the chance of patients developing colon cancer. The combined application of laparoscopy and choledochoscopy with extracorporeal direct vision minimally invasive biliary stone extraction for the treatment of gallbladder stones can eliminate gallbladder and extra-biliary complications caused by gallbladder stones, and avoid complications such as bile duct and blood vessel damage that may be caused by cholecystectomy because the gallbladder triangle does not have to be dissected. It has the advantages of minimal trauma, easy operation, safer and more reliable patient, less pain, shorter hospital stay, faster recovery, less complications, etc. It maintains the integrity of the bile duct and the function of the gallbladder after surgery, which is in line with the modern view of minimally invasive surgery and stress theory, and is a reasonable and effective procedure for the treatment of gallbladder stone disease, with good clinical application prospects. (Li Bin, Department of Hepatobiliary Medicine)