**1. Introduction**

Cholecystectomy is the primary treatment of cholelithiasis. But the prevention of the formation and the dissolution of the stones were popular in the 80's . The clinical use of the chenodeoxycholic and after the ursodeoxycholic acid emerged in the 70's, when proved that this acids reduced biliary cholesterol saturation in bile. Important aspects were significant but reversible hepatotoxicity in 3%, diarrhea in 8%, abandonment of treatment in 15% and a similar proportion of abdominal pain. Probably, more important was the increase in total serum cholesterol and low density lipoprotein during treatment with chenodesoxycholic acid. In general, ursodeoxycholic acid appears to have fewer side effects, works faster and causes less liver damage. In patients with small cholesterol stones and floating radiolucent treated with ursodeoxycholic acid, for 6-12 months, partial or complete dissolution can be expected in 40-55% of cases.

The direct dissolution of cholesterol gallstones using methyl tert-butyl ether (MBTE) requires the insertion of a percutaneous transhepatic catheter in the gallbladder. The MBTE (5-10 mL) should be infused in a manner that involves the calculi but does not flow into the common bile duct and duodenum. In 4-16 hours the stones are dissolved. The patient should stay overnight in the hospital. Side effects include pain and nausea; haemolysis and duodenitis are serious consequences of the spilling of the solvent into the duodenum . Transabdominal mechanical lithotripsy is another treatment modality, which leads to fragmentation of the stones in selected cases in almost 100% of patients.

All of these treatments have in common the recurrence of stones (from 45% to 70% at 5 or 7 years of follow-up), due to persistence of a place for the precipitation of cholesterol crystals (gallbladder) and bile prone to precipitate (lithogenic bile). A report by Gilliland and Traverso in 1990 settled any doubts about the alternatives in the treatment of cholelithiasis (Gilliland & Traverso, 1990) These authors reviewed outcomes of 671 cholecystectomy patients during the years 1982-1987 and found no mortality and 2.2% of complications. They conclude that open cholecystectomy is a definitive treatment for symptomatic cholelithiasis with minimal risk to the patient and a high degree of cure of the symptoms.

Transcylindrical Cholecystectomy for the Treatment

cholecystectomies performed annually in the United States.

**1.3 Laparoscopic cholecystectomy – Eric Mühe** 


hat notice of it until 1996 with the Litynski´s. book.

adhesions, hernias and, above all, pain.


too.

latter describes the technique of cholecystectomy by minilaparotomy.

of Cholelithiasis and Its Complications: Cholecystectomy Under Local Anesthesia 5

see the savings produced by minilaparotomy, especially if applied to the 600,000

Despite these and further studies, minilaparotomy was never popular. For example, out of seven standard textbooks: Norton al al., (Harris, 2008). Sabiston (Arendt & Pitt, 2004), Schwartz (Schwatz 1989), Doherty (Doherty, 2010), Maingot (Karam & Roslyn, 1997), Marlow & Sherlock (Dawnson, 1985). Morris & Malt (Britton & Bickerstaff, 1994), only the

Laparoscopy has not only caused a revolution in the treatment of cholelithiasis, but that has changed an old surgical proverb: "a large incision, a great surgeon." It seems reasonable to assert that "a smaller incision, less abdominal wall trauma and better aesthetic results." The era of minimally invasive surgery began and laparoscopy has been extended to almost all abdominal surgical operation and almost any procedure has been performed by

Interestingly, laparoscopic cholecystectomy was not well received by the German Surgical Society when E. Mühe reported the first operation in 1986. On September 12, 1985, Mühe selected with great care the first patient to perform the first laparoscopic cholecystectomy, almost five years after the first laparoscopic appendectomy by Semm. Like him, Mühe performed the pneumoperitoneum with the Veress needle, inserted the trocar and introduced his own "galloscope" through the umbilicus. Two hours later he concluded successfully the first laparoscopic cholecystectomy (Litynski, 1996). His presentation at the congress was not published and only a summary appeared in Langenbecks Archiv für Chirurgie 1986 (Mühe, 1986). However, with subsequent amendments Mühe concluded that inserting the laparoscope (galloscope) as close as possible to the gallbladder the "cumbersome" pneumoperitoneum could be avoided. After several cholecystectomies without gas, trying to simplify and adapt the technique to be used by most surgeons, he realized that the optical instrument was not necessary, "with or without galloscope, the magic surgical approach could be the same". Soon operated through sheath of the

laparoscopic approach, including resections and all types of gastrointestinal suture.

galloscope without the optical instrument with the advantages of minimal incision:


This outlined the bases of minimally invasive surgery. Sadly, Mühe didn´t publish the evolution of his technique for cholecystectomy in any international journal and we haven´t

2. The trauma to the abdominal wall caused by an incision about 15 cm is large and has a well-known impact on the respiratory physiology, a greater possibility of formation of

3. The acceptance by the patient has been quick, because it was publicized with all of the above advantages. The charisma of laparoscopic technology is undeniable, its elegance,

Many reasons can be considered to explain the success of laparoscopic cholecystectomy: 1. It is obvious that the ports, about 1 cm, scattered in the upper abdomen and a umbilical

opening for the introduction of optic, produce a minimal aesthetic disorder.



The first truly major surgery on the biliary tract was performed in 1867 in Indiana (USA). John S. Bobbs, professor of surgery at the Medical College of Indiana, operates a tumor in the right upper quadrant in a 30 year old woman, at home and under general anesthesia, resulting in the diagnosis of gallbladder hydrops which was evacuated and drained. It was the first cholecystostomy performed in the history.

Fifteen years later, in 1882, Carl J. Langenbush of Berlin performed the first cholecystectomy by lithiasis, after exercising cholecystectomy in cadavers for several years. However, as more than a century later would happen with the laparoscopy and in the same Germany, Langenbush's communication in the German Congress of Surgery of three cases of cholecystectomy that evolved successfully, was received with apathy and without due consideration that the time reserved.
