F . A . C . S . , and Dennis R . Klassen , M . D . 21 CHOLECYSTECTOMY AND COMMON BILE DUCT EXPLORATION

Cholecystectomy is the treatment of choice for symptomatic gallstones because it removes the organ that contributes to both the formation of gallstones and the complications ensuing from them.1 The morbidity associated with cholecystectomy is attributable to injury to the abdominal wall in the process of gaining access to the gallbladder (i.e., the incision in the abdominal wall and its closure) or to inadvertent injury to surrounding structures during dissection of the gallbladder. Efforts to diminish the morbidity of open cholecystectomy have led to the development of laparoscopic cholecystectomy, made possible by modern optics and video technology. Carl Langenbuch performed the first cholecystectomy in Berlin, Germany, in 1882. Erich Mühe performed the first laparoscopic cholecystectomy in Germany in 1985,2 and by 1992, 90% of cholecystectomies in the United States were being performed laparoscopically. Compared with open cholecystectomy, the laparoscopic approach has dramatically reduced hospital stay, postoperative pain, and convalescent time. However, rapid adoption of laparoscopic cholecystectomy as the so-called gold standard for treatment of symptomatic gallstone disease was associated with complications, including an increased incidence of major bile duct injuries. Since the early 1990s, considerable advances have been made in instrumentation and equipment, and a great deal of experience with laparoscopic cholecystectomy has been amassed worldwide. Of particular significance is the miniaturization and improvement of optics and instruments, which has reduced the morbidity of the procedure by making possible ever-smaller incisions.With proper patient selection and preparation, laparoscopic cholecystectomy is being safely performed on an outpatient basis in many centers.3 The primary goal of cholecystectomy is removal of the gallbladder with minimal risk of injury to the bile ducts and surrounding structures. Our approach is designed to maximize the safety of both routine and complicated cholecystectomies. In what follows, we describe our approach and discuss current indications and techniques for imaging and exploring the common bile duct (CBD).