Cholecystectomy is based on the principle of preserving a functioning organ. Preservation of the gallbladder can be beneficial for some patients with gallbladder stones and is a change in philosophy from cholecystectomy. The author discusses several common problems in gallbladder stone extraction and presents the author’s views on these issues.
Gallbladder stones are a common and frequent disease affecting human health, and minimally invasive cholecystectomy has become a hot topic for surgeons in China in recent years. After the First National Endoscopic Gallstone Retrieval Conference held in December 2007 in Guangzhou, the Second National Endoscopic Minimally Invasive Gallstone Retrieval Conference was held in August 2009 in Beijing Shougang Hospital, where various views were expressed.
The removal of stone polyps and selective preservation of the gallbladder is a new way of thinking, which is changing the traditional surgical method and the medical method for the purpose of treating diseases, reflecting the new medical concept of “human health as the center”. However, there are still many uncertainties in the process of biliary preservation, which needs to be observed clinically. In this paper, we present our views on several issues that should be considered in biliary preservation surgery, in the context of the minimally invasive biliary stone extraction surgery carried out in our hospital in recent years.
1.The controversy between bile-cutting and biliary stone extraction
The controversy over whether to remove or preserve the gallbladder for the treatment of gallbladder stones began when the concept of gallbladder preservation was introduced, and in 1882, the German physician Langenbuch proposed the theory that “gallbladder removal is not due to the presence of stones in the gallbladder, but to the ability of the gallbladder to grow stones”, which was later called the hotbed theory, He proposed that the treatment of gallbladder stones and polyps should be performed by cholecystectomy. In 1987, Dr. Phillpe Mouret, an obstetrician and gynecologist in Lyon, France, performed the world’s first laparoscopic cholecystectomy on a female patient in 2.5 hours, enabling the use of minimally invasive techniques in gallbladder removal.
Laparoscopic cholecystectomy (LC) is widely accepted by patients because of its low trauma, low pain, fast recovery and good aesthetic effect. Since February 1991, laparoscopic cholecystectomy has been performed in China, and thousands of patients with gallbladder stones have undergone laparoscopic cholecystectomy. Moreover, the progress of laparoscopic technology has deepened with the extension of surgical practice, with LC reduced from four holes to three holes, two holes, or even one hole for gallbladder removal, and European and American countries have focused their laparoscopic attention on the da Vinci system. The combination of laparoscopy with choledochoscopy and duodenoscopy has expanded the surgeon’s means of treating gallbladder and bile duct stones.
The concept of biliary preservation is based on the development of laparoscopic and endoscopic techniques, unlike traditional stone extraction methods, which are operated under direct endoscopic vision, highly controllable, with high stone extraction rate and require a certain technical level of operation. The gallbladder is not a dispensable organ in the body, and selective preservation of the gallbladder may be beneficial to the patient.
Among these arguments, the resectionists believe that the recurrence rate of gallbladder stones is high and patients will suffer from secondary pain, while the cholecystectomy is more complete. The biliary preservationists believe that gallbladder resection will lead to postoperative dyspepsia, abdominal distension, diarrhea, intraoperative biliary tract injury, postoperative common bile duct stone incidence, and other complications. In recent years, the author’s practice of biliary preservation has shown that gallbladder stones should be treated individually with a combination of excision and preservation, neither all gallbladders are removed nor all gallbladders are preserved. Patients who are suitable for biliary preservation should have their gallbladder preserved; patients who are not suitable for biliary preservation should have their gallbladder removed. The standardized indications and contraindications for surgery should be followed.
2.Standardized development
Biliary stone preservation is developing rapidly. Huang Zhiqiang and Qiu Fazu both gave high praise to the concept of biliary lithotripsy. Huang Zhiqiang pointed out that “the new thinking of endoscopic biliary technology is a major event in the 21st century and a major event in China”. Qiu Fazu clearly stated: “We have to protect the gallbladder”. Professor Ran Ruitu pointed out that “gallbladder stones originate from the liver, and the indications for cholecystectomy should be modified”. These views unified everyone’s thinking at an early stage and gave strong support for biliary lithotripsy; at the same time, the patient’s strong desire to preserve the organ also provided the basis for biliary lithotripsy. These factors have contributed to the rapid development of biliary lithotripsy. In this context, it is important to consider the “normative development” and the following issues.
2. 1 The problem of standardization
At present, the phenomenon of biliary lithotripsy is a rash phenomenon, with tertiary hospitals performing it, secondary hospitals starting to do it, and township hospitals also starting to do it. This has led to irregularities in technical operation and unbalanced development levels. Some hospitals are not equipped with the basic laparoscopy and cholangioscopy, but they advertise biliary surgery. In fact, they adopt the old method of stone extraction, which is to open the gallbladder, remove the stones with forceps, and use hand touch to determine whether the stones are removed, which results in a higher recurrence rate of stones. The authors believe that the solution to these problems is to use the same methods as those used in the previous study. The authors believe that the solutions to these problems are:
( 1 ) There should be an access mechanism, and the conditions and personnel of each hospital should be evaluated for biliary surgery as for transplantation, and a threshold should be set.
( 2 ) To establish a training mechanism, biliary surgery requires that the operator must have the ability to remove the gallbladder openly and laparoscopically, and be able to operate the cholangioscope skillfully, which requires a great improvement over a single operation, and it is very necessary to conduct training to coordinate the eye-hand movements before carrying out biliary surgery. Through the training, we can understand the purpose of the procedure and be familiar with the procedure steps so that we can operate gently and accurately and reduce repetitive movements.
The current training method is: simulation box training – animal practice, the simulation box is very realistic, can be equivalent to the operation of the operating room, coupled with the instructor’s guidance, the trainer can quickly master the basic operation of biliary preservation, simulation box simulation of various intraoperative scenarios and animal practice such as bleeding, biliary fistula, etc., can train the operator’s clinical decision-making and response capabilities. Through the training, the operator’s self-confidence in completing the surgery can also be enhanced, and the surgery can be carried out better.
2. 2.2 Indications for surgery
The second issue that needs to be considered in the development of standardization is to grasp the indications for surgery.15 In the initial stage of biliary lithotripsy, the indications for biliary surgery were proposed to be the following three points:
( 1 ) Good gallbladder function;
( 2 ) Patients with no or mild right upper abdominal pain and mild inflammation;
( 3 ) No more than 3 single or multiple stones. The reason for this is that the functional gallbladder can be preserved to concentrate the bile, and the gallbladder can contract after eating. For patients with more than 3 stones, the possibility of stone retention increases, so biliary preservation is not recommended for patients with multiple stones. However, with years of practice, the indications are expanding. Many surgeons, after becoming surgically proficient, have started biliary preservation surgery for patients with multiple stones or filled stones, with good results.
In patients with gallbladder stones complicated by common bile duct stones, the author performed preoperative ERCP to remove the stones, and the bile was successfully preserved; in patients with embedded stones in the bile ducts, the author used lithotripter to remove the stones after lithotripsy, and the bile was also successfully preserved.
Previously, poor gallbladder contraction is considered a contraindication. However, the author’s clinical experience shows that in some patients with poorly contracted gallbladder, intraoperative laparoscopic investigation reveals that the inflammation of the gallbladder is not serious, and even if there are some adhesions, bile can still be preserved by releasing the adhesions and removing the stones, and there is bile flow in the gallbladder duct. The reason for the expansion of the indications is the accumulation of experience and the improvement of surgical instruments. In order to benefit more patients with gallstones, some scholars have proposed the requirement of “modification of indications”.
In the author’s opinion, the indications should be based on the operator’s personal experience, and the indications should be strictly controlled in the early stage to ensure the success rate. However, one thing that should always be grasped is that the stones should be removed, the functional gallbladder should be preserved, and the contraindications should not be ignored. In the author’s opinion, the currently accepted indications are:
( 1 ) Good gallbladder function;
( 2 ) No history of acute cholecystitis, gallbladder wall < 4 mm;
(Among the original contraindications, the author believes that the choledocholithiasis and common bile duct stones should be removed; in case of poor gallbladder contraction, the decision of biliary preservation should be made after laparoscopic exploration.
2. 3 Surgical techniques and methods
The third issue of normative development is the surgical approach, which includes two aspects:
One is the surgical approach,
Second, the rational use of flexible and rigid scopes. At present, the common surgical methods are:
( 1 ) Small incision, that is, a small incision of about 3-4 cm is made at the projection of the gallbladder body, the gallbladder is lifted out of the body, a small incision is made at the bottom of the gallbladder, a choledochoscope is inserted, the stones are removed, the gallbladder is closed with absorbable sutures and the abdomen is closed.
( 2 ) Laparoscopic method, that is, laparoscopic operation of biliary preservation method.
( 3) Laparoscopic-assisted biliary preservation method, in which the laparoscope is first used to investigate, determine the location of the gallbladder, and clamp the gallbladder, and then use a small incision method to preserve the gallbladder. All three surgical methods are minimally invasive. In the author’s opinion, we should choose the surgical method that suits our conditions. The use of soft and rigid mirrors has its own advantages and disadvantages. The soft mirror is more curved and has a wider field of view, but it is less effective for interstitial stones; the rigid mirror is more effective for interstitial stones, but it cannot be folded back and the field of view is limited. If the two are used together, it will be more convenient for surgical operation. The concept of interstitial stones is important to note. Usually, the wall of the gallbladder is only 0.2-0.3 cm, so the possibility of stones in such a thin wall is very small, and interstitial stones refer to small stones in the sinus of Roa.
3. About the recurrence of gallbladder stones
Recurrence of gallstones has always been a major obstacle to the development of biliary stone extraction. The recurrence rate of gallstones in the old method of biliary stone extraction is as high as 30% to 50%, while Zhang Baoshan et al. reported in 2009 that the recurrence rate was 3. 9% at 15 years in 577 cases of biliary surgery. The recurrence of gallstones is caused by the missed stones because the stones were not removed or the interstitial stones could not be removed, and the recurrence after many years.
The author’s experience is that if the stones are removed intraoperatively, there will be no recurrence in the short term (within one year). To prevent recurrence of gallstones, we need to “eliminate leakage and reduce recurrence”. Some surgeons routinely perform ultrasound after biliary stone extraction; some surgeons perform intraoperative imaging to determine whether the stones have been removed, which is useful to prevent leakage. Reducing recurrence is a matter of stone prevention. Patients after biliary stone extraction should pay attention to postoperative treatment, such as drinking more water and avoiding high-fat diet; changing the habit of skipping breakfast; especially, the postoperative treatment should be supplemented with certain choleretic drugs to reduce the recurrence rate to a greater extent.
4.Innovation of bile stone extraction research thinking
The so-called innovation is for the purpose of development, for a certain problem, based on the inheritance of existing knowledge and experience, boldly break through the conventional and traditional, and strive to form new things, new programs, new designs, new technologies, new theories of activity. The starting point of innovation is to propose a problem, which is often more important than solving a problem; the key to innovation is to break through, to break through the conventional precepts; the essence of innovation is novelty, the meaning of innovation is “new”; the basis of innovation is inheritance; the purpose of innovation is development.
Biliary lithotripsy is an operation that is beneficial to the health of patients by preserving the functional organs. Through years of exploration, the theoretical basis and feasible surgical methods have been formed. Young surgeons should combine “learning and innovation” in biliary lithotripsy. What is more important is to innovate the concept and surgical approach. For example, scholars have different opinions on the use of flexible and rigid mirrors, each claiming to be better than the other, but in fact, each has its own shortcomings. In addition, after the gallbladder is removed from the abdominal cavity, saline needs to be injected to maintain the volume of the gallbladder and to ensure a clear view.
We need to consider whether the gallbladder can be propped open to maintain a certain size and facilitate the operation, and whether there are better postoperative medications than the current cholestatic drugs. The current status of research on biliary lithotripsy is that there are many single-center reports, but there is a lack of multicenter, prospective controlled studies and long-term follow-up, so it is difficult to obtain convincing statistical data to explain the problem.
In conclusion, biliary stone extraction is less invasive, more effective, and preserves the organs, although there are still problems of recurrence, but we believe that through our work, it will be improved to serve the majority of patients.