Figure: laparoscopic incision of the gallbladder; choledochoscopy-assisted or direct removal of stones in the gallbladder; absorbable suture closure of the gallbladder.
1. The past life of gallbladder stone extraction
Gallbladder stones are a common disease. Since gallbladder stones can cause biliary colic, acute cholecystitis, secondary common bile duct stones, acute pancreatitis and even gallbladder cancer and other comorbidities, active treatment is generally required for gallbladder stones. The current treatment of gallbladder stones is mainly divided into two categories: the traditional method is cholecystectomy; removing stones and preserving gallbladder is a new view.
The earliest “cholecystectomy” was performed under the open abdomen to retrieve the gallbladder, and was used as a surgical procedure for gallbladder stones before Langenbuch, a famous German surgeon, performed the first cholecystectomy in 1882. Langenbuch’s invention of cholecystectomy was gradually eliminated, and open cholecystectomy was occasionally used for cholecystostomy in critically ill patients with septic cholecystitis, often requiring a second-stage cholecystectomy.
In recent years, due to the popularity of minimally invasive means, especially laparoscopy and choledochoscopy have been widely used in biliary surgery. In Germany, Frimberger first reported 34 cases of Laparoscopic cholecystotomy (LCT) in 1992 (Endoscopy, 1992, 24:717-20; this is the same as the Chinese term “minimally invasive cholecystectomy”). “In 2002, Zhang Baoshan of Peking University First Hospital summarized the results of 895 cases of minimally invasive cholecystectomy at several hospitals and reported a recurrence rate of 2.7%-4.1% for stones 1-6 years after surgery. Subsequently, biliary stone removal surgery in China has shown a booming trend and is highly sought after by patients to meet the psychological demand of preserving body organs.
Compared to cholecystectomy, biliary lithotripsy relatively broadens the indications for gallbladder surgery, because about 20-40% of the gallbladder stone population are stationary stones, which may remain asymptomatic for life and may not have complications related to gallstone disease, and usually require no special treatment and only regular follow-up. Biliary lithotripsy can include these patients in the indication for surgical treatment.
2. Stone recurrence rate of minimally invasive biliary lithotripsy
In 2009, Liu Jingshan et al. showed a cumulative 10-year recurrence rate of 10.1% in 612 LCT cases with long-term follow-up. Such recurrent stones occur mostly on the basis of rapidly formed cholesterol crystals and can theoretically be prevented by oral bile salts.
The recurrence of stones is the focus of controversy in academic circles. Some patients in the society strongly request physicians to perform biliary preservation surgery despite the clinical indications. Most of the hepatobiliary surgeons in large tertiary hospitals in China take a relatively conservative attitude toward this type of surgery, and there are few reports of biliary lithotripsy abroad.
3.The pros and cons of minimally invasive cholecystectomy
Laparoscopic cholecystectomy is still the accepted “gold standard” for the treatment of symptomatic gallbladder stones. In contrast to the extremely large number of cholecystectomies performed annually worldwide, cholecystectomy can be a useful addition to the “individualized” treatment options for benign gallbladder disease, and the advantages should outweigh the disadvantages in carefully selected cases.
From a technical point of view, biliary lithotripsy can be performed in any hospital with the technology and equipment, as it does not require dissection of the gallbladder triangle, dissection of the cystic duct and gallbladder artery, and is generally less difficult and risky than cholecystectomy.
The authors believe that whether surgeons accept or reject minimally invasive biliary lithotripsy, it is a scientific attitude to perform biliary lithotripsy on strictly screened gallstone cases after careful evaluation and to recognize minimally invasive biliary lithotripsy after first-hand experience, as long as the patient has a need for it, and only then can the patient’s benefit be maximized. The long-term efficacy of minimally invasive biliary lithotripsy surgery can be evaluated through prospective multicenter clinical trials.
4. Focused debates on minimally invasive biliary lithotripsy
4.1 Stone recurrence The causes of gallbladder stone formation are multifaceted and largely related to chronic inflammation of the gallbladder, reduced contractile function of the gallbladder, bile metabolism and changes in the patient’s age and hormone level, diet and lifestyle. For simple cholesterol stones in the gallbladder, postoperative oral ursodeoxycholic acid can reduce the risk of stone recurrence.
4.2 Gallbladder removal or preservation Gallbladder preservation mostly emphasizes the importance of preserving the gallbladder and the dangers of removing it. It is true that removal of a healthy and functional organ is something that surgeons strive to avoid, but preservation of an organ with organic pathology, such as irreversible chronic inflammation and the presence of precancerous conditions, is likewise something that surgeons need to strive to avoid. This concerns the long-term outcome of the patient and is one of the blind spots in the current understanding of minimally invasive biliary stone extraction.
5. Indications and contraindications for minimally invasive biliary lithotripsy The following indications and contraindications can be mutually transformed under certain circumstances. However, in general, the current selection of candidates for biliary stone extraction should be strictly screened and carefully promoted to avoid future reoperation. Especially for elderly patients, once the stones recur after several years, the body may be too weakened to tolerate another surgery.
Indications.
1, asymptomatic quiescent gallbladder stones; 2, the gallbladder must have good contractile function: oral cholecystography or ultrasound after a lipid meal showing gallbladder contraction of more than 1/3; 3, the gallbladder must not be too large or too small, and there must be no separation within the cyst; 4, the upper abdomen should preferably have no history of open surgery, perforation or other acute inflammatory disease; 5, the gallbladder mucosa is smooth, the thickness of the gallbladder wall ≤ 3 mm, and the stones are single or multiple (sediment except for sediment-like stones).
Contraindications.
1, atrophy of the gallbladder, significant thickening of the gallbladder wall; 2, combined with common bile duct stones; 3, stones in the gallbladder duct cannot be removed; 4, combined with Mirizzi syndrome; 5, complete loss of gallbladder function, porcelain gallbladder or combined with adenomatous polyps, or combined with adenomyosis; 6, multiple sediment-like gallbladder stones; 7, elderly patients; 8, people with high risk factors for gallbladder stones, such as heavy obesity, overeating, etc.