Therapeutic splitting: Is there a need for intraoperative cholangiography and operative common bile duct exploration?

The role of therapeutic splitting in cases of cholecystolithiasis and choledocholithiasis has to be reviewed since laparoscopic bile duct exploration might be an altemative. To assess the need of the new approach we evaluated our results of the therapeutic splitting. Between 1988-1992 a cholecystectomy was performed in 577 cases either as an open (n=274) or laparoscopic (n=277) procedure. Pre- or postoperative endoscopic retrograde cholangiopancreatography (ERC/P) was performed if the clinical presentation, laboratory findings or ultrasound showed signs of choledocholithiasis. In the laparoscopic cases no intraoperative cholangiography was carried out. The patient follow-up was evaluated by a questionnaire. 128 patients were suggested to have a common bile duct (CBD) stone and had a preoperative ERC/P. In 68 cases stones were extracted. After cholecystectomy 19 ERC/P's were performed. In 4 patients residual stones after preoperative ERC/P were detected. So far occult stones were found in 5 cases. Intraoperative cholangiography was performed additionally in the patients with open cholecystectomy (n = 207), of whom two demonstrated choledocholithiasis. Endoscopic clearance of the common bile duct was achieved in all patients. Minor complications occurred after ERC/P in 1.5 %. Within a median follow-up time of 48 months patients with endoscopic papillotomy did not develop further CBD stones or a cholangitis. The therapeutical splitting facilitates in all patients with cholecysto- or choledocholithiasis a successful clearance of the CBD. Intraoperative cholangiography is not necessary according to our experience. With an experienced endoscopic team the therapeutic splitting should be the prefered treatment modality compared to the laparoscopic bile duct exploration, which will probably lead to a high complication rate if performed outside specialized centers.