Teaching gall bladder surgery: remembrance of things past, or defensive cholecystectomy revisited

Among the remaining concerns for surgeons performing laparoscopic cholecystectomy are the incidence of bile duct injury and the rate of conversion to open operation. The open operation itself, now infrequently performed, and then only for complicated disease, poses a particular challenge to the surgeon in training. The lessons learned from the era of open cholecystectomy as summarized in the principles of defensive cholecystectomy, provide useful guidelines for the laparoscopic surgeon, particularly with regard to the objectives of dissection in Calot's triangle. Attainment of these objectives during laparoscopic cholecystectomy may be easily recorded and are useful exercises for teaching and quality assurance. Flexibility with laparoscopic dissection can be taught to reflect the development of the laparoscopic technique and should allow most patients with gallstones to be treated laparoscopically. Alternative operations (cholecystostomy and subtotal cholecystectomy) may be appropriately performed laparoscopically in the occasional patient where safe cholecystectomy may not be possible by either technique. Whenever the opportunity arises, open cholecystectomy should be carefully taught to the trainee surgeon, emphasizing the principles of defensive cholecystectomy.