The current controversies over video laparoscopic cholecystectomy as the treatment of choice for cholelithiasis

Recently, the widespread use of laparoscopic cholecystectomy allowed to reach several goals such as a minimal invasive approach, a minimal operative trauma, the absence of aesthetic or functional damage of the abdominal wall, and a quick return to full activities. On the other hand, as all innovations, laparoscopic cholecystectomy is matter of debate and a number of controversies have recently appeared in the Scientific Literature. On the basis of their experience and through a critical review of the Literature, the Authors have therefore analyzed possible solutions to such controversies. Particularly, current indications and contraindications of this approach, surgical technique and relative sites of insertion of the trocars, the need to drain or not, the pre- and intra-operative study of the bile duct and the approach in case of bile duct stones pre- or intra-operatively demonstrated, have been evaluated as possible answers. The Authors conclude that indications to laparoscopic cholecystectomy are the same of those for laparotomy, contraindications are represented by coagulopathies, liver cirrhosis and plastic peritonitis. At present it is still impossible to affirm which is the best surgical technique, the best position for the surgeon, and the best site for the insertion of the trocars, while drainage must be used only in those cases in which further manoeuvres on the bile duct are required. At last the Authors underline there is no need for a routine intraoperative cholangiography during laparoscopic cholecystectomy, however such technique must be known by laparoscopic surgeons since it may be mandatory in some selected cases. ERCP, on the contrary, is a valid support to laparoscopic cholecystectomy in the treatment of gallbladder stones associated with bile duct stones.