Various strategies have been proposed for the treatment of common bile duct stones encountered during laparoscopic cholecystectomy (LC). Eighty-three patients who had choledocholithiasis discovered during or just prior to LC are included in this study. These patients were treated by various modalities including preoperative, intraoperative, and postoperative endoscopic retrograde cholangiopancreatography and sphincterotomy, laparoscopic choledochotomy, transcystic duct-common bile duct (TCD-CBD) exploration, and conventional "open" common duct exploration. Sixty-six patients were successfully treated with TCD-CBD exploration. They were discharged on average 2.6 days postoperatively and were able to return to normal physical activities within 7 days of discharge. There was minimal morbidity and no mortality. The technique of TCD-CBD exploration is described in detail. The role of laparoscopic choledochotomy and endoscopic sphincterotomy for management of common duct stones in patients undergoing laparoscopic cholecystectomy appears limited.

The potential application of ultrasonic energy for ablation of atherosclerotic plaques was studied in human atherosclerotic arteries with continuous and pulsed delivery of energy. With a prototype ultrasonic wire probe (n=79 segments), there was gross reduction in vascular lesions as well as microscopic disruption of fibrous and calcified plaques. Normal portions of vessels appeared unaffected by the application of ultrasound. The prototype ultrasonic wire catheter ablated calcific deposits in less than 10 seconds. With this probe, all 26 complete atherosclerotic occlusions 0.5-5 cm in length were recanalized irrespective of the presence of calcium. Twenty-four of the segments were reopened in less than 20 seconds. By light microscopy, the site of plaque ablation was smooth, concave, and conformed to the shape of the probe tip. In 17 samples, there was evidence of thermal injury, and in six of the 79 samples studied with the prototype probe, there was vascular perforation. No vascular perforation occurred without thermal damage, when pulsed (rather than continuous) ultrasonic energy was used (n=40) or when the duration of application was less than 30 seconds, with power output less than 25 W and with the probe oriented parallel to the wall (n=26). Thus, by modifying the duration, mode, and magnitude of the ultrasonic power output, thermal injury and vascular perforation may be avoided. In vivo intra-arterial ultrasonic angioplasty of a canine chronic femoral fibrocellular occlusion was also performed. A preliminary in vivo study demonstrated feasibility of the percutaneous application of intra-arterial ultrasonic recanalization. Thus, ultrasonic energy appears to have potential as a method for ablation of occlusive atherosclerotic plaque. (Circulation 1988;78:1443-1448 B alloon angioplasty has three unresolved limitations: complete obstructions, multisegment multivessel disease, and late resteno SiS.1,2 To resolve these problems, a variety of new techniques are being investigated, including hot-tip thermal probes,3,4 several types of laser radiation methods,5-8 atherectomy catheters,9 and highspeed drills.'0 l l Each of these technologies also has limitations, principally relating to endothelial damage and perforation.In the present study, we examine ultrasound as an alternate ablation energy source. Ultrasonic lithotripsy has been shown to be effective in the destruction of renal and ureteral calculi. 12-17 Surgical ultrasound has also been used for the disintegration of gallstones,'8 for dental plaque removal,'9 in facilitating excision of intracranial20 and hepatic tumors,2' and for debridement of heavily calcified cardiac valves.'9 In addition, surgical ultrasound has been Address for correspondence: Robert J. Siegel, MD

With increasing acceptance of routine cholangiography during laparoscopic cholecystectomy (for confirmation of anatomy) there has been increased identification of common duct calculi. A technique of laparoscopic transcystic common duct stone extraction is described and early clinical results are presented. Successful stone extraction was accomplished in 39 out of 41 consecutive attempts by one surgical team. Two cases required choledochotomy. There were four complications including hyperamylasemia (2), minor wound infection (1), and incidental pneumothorax (1). Recommendations regarding safety and indications are presented. Initial evaluation suggests laparoscopic transcystic stone extraction is safe and effective.

Laparoscopic cholecystectomy is rapidly evolving as a therapeutic modality for the treatment of gallstone disease. The technical details of this procedure and the method by which the gallbladder is dissected and removed are critical to the safe, effective execution of the procedure. Our technique has been developed through extensive practice in porcine models and through experience with more than 250 patients. To perform laparoscopic cholecystectomy we employ a high-resolution video endoscopy system, two high-resolution color monitors, a high-flow CO2 insufflator, a 300 W Xenon light source, electrocautery and/or lasers, and an endoscopic suction-irrigation system. This equipment permits the surgeon to obtain a clear field of view within the abdomen. With these tools, appropriately designed for laparoscopic surgery, including a laparoscope, graspers, dissectors, cholangiography equipment, scissors, and clip appliers, the surgeon can remove the gallbladder without opening the abdomen. The procedure requires the induction of a CO2 pneumoperitoneum, insertion of four trocars, and placement of a grasping retractor to set the operative field. An additional retractor placed on Hartmann's pouch provides countertraction for dissection of the hilum. Careful dissection around the cystic duct and cystic artery with a combination of electrocautery and blunt dissection allows the surgeon to skeletonize the cystic duct and artery. After intraoperative cholangiography confirms the anatomy, the cystic artery and cystic duct are clipped and divided. Electrocautery or laser techniques can be used to perform retrograde dissection of the gallbladder from the liver bed and insure hemostasis. The gallbladder is detached and removed intact through the large trocars. This basic technique can be applied in a wide variety of patients with cholelithiasis. The surgeon proficient in this technique may apply it to a broad range of patients with gallbladder disease.