Chapter 1: Historical Prespective

The first cholecystectomy has been attributed to Dr. Karl Langenbuch, a surgeon in Berlin in 1882. Within a decade, cholecystectomy was being combined with exploration of the bile duct in selected patients with jaundice or cholangitis. By 1900, additional surgical procedures had been described including cholecystoenterostomy, choledochoduodenostomy, and operative sphincteroplasty. At a similar time, operative drainage of the bile duct using a T-lube was described by another German surgeon Dr. Hans Kehr (David 2008).

          The first description of operative cholangiography has been attributed to Dr. P. Mirizzi in Argentina. In 1931, he described the intraoperative injection of lipiodol through the cystic duct. This procedure increased the detection of unsuspected bile duct stones and decreased the frequency of unnecessary bile duct explorations. Subsequently, percutaneous transhepatic cholangiography was described, but the procedure was not widely adopted until the introduction of the Chiba needle by Dr. K. Okuda in Japan in 1973. More recently, sophisticated radiological equipment has been installed in operating suites to provide both fluoroscopic and static images of the bile duct (Morgenstern 1997).

            Developments in radiological techniques were associated with the evolution of endoscopic techniques for direct visualization of the bile duct. Although rigid choledochoscopy had been described in the 1940s, it was not until the 1960s that optical systems were good enough to promote their widespread use. Within a decade, some of these instruments had been replaced by flexible fiberoptic choledochoscopes. Flexible choledochoscopes have also been used to extract retained bile duct stones through the T-tube tract, and to perform diagnostic and therapeutic procedures after percutaneous transhepatic passage into the bile duct (Morgenstern 1997).

         Another major step forward was the introduction of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy. Although sphincterotomy was first described in 1973, the procedure became widely available only in the early 1980s. Subsequently, sphincterotomy became a common procedure for patients with bile duct stones prior to cholecystectomy and became the procedure of choice for removal of bile duct stones after cholecystectomy (Petelin et al., 2004).

          Laparoscopic cholecystectomy was introduced in the late 1980s, and by the mid-1990s replaced open cholecystectomy as standard treatment for gallbladder stones. A particular concern, however, was the development of complications in patients with coexisting bile duct stones. Initially, many patients underwent ERCP prior to laparoscopic cholecystectomy to exclude bile duct stones. Subsequently there was a more rational use of ERCP as well as the development or laparoscopic exploration or the bile duct. The latter procedure, in particular is still in an evolutionary phase but individual surgeons claim laparoscopic extraction of bile duct stones in up to 90% of patients. These results are comparable to those achieved with endoscopic sphincterotomy and open exploration of the bile duct (Morgenstern 1997).

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