History of Biliary Surgery

History of Biliary SurgerySpirou Yannos •Petrou Athanasios •Christoforides Christos •Felekouras EvangelosÓSocie´te ´Internationale de Chirurgie 2013Abstract Since ancient times biliary surgery has been one of the major interests of doctors and other scientists around the world.From the ancient Greeks and Egyptians to the greatest scientists of modern times biliary surgery has advanced remarkably.Especially during the last cen-tury huge progress has been made in this field.Minimally invasive surgical techniques have been developed and combined with general anesthesia and antisepsis that have made biliary surgery particularly safe for every patient and have made cholecystectomy one of the most common operations in the world today.Ancient timesThe history of gallstones is probably as old as the evolution of humans.The first documented descriptions are likely those that tell of gallstones in Egyptian mummies dating back nearly 2,000years before Christ.Long before the Roman Empire,the liver and biliary tract passages were known and were thought to be divine.Early medical papyri of Egypt dating to the pyramid builders,3,000years B .C .E ,indicated that surgical conditions were skillfully treated.A mummy was presented in 1909to the Museum of Royal College of Surgeons in London.It was of the 21st dynasty (circa 1500B .C .E .)that had a preserved liver and a large gallbladder containing 30gallstones.It was the earliest specimen of calculi surviving from antiquity.Unfortu-nately,it was destroyed by German bombing in World War II [1,2].On the Island of Cos the great Hippocrates (460–370B .C .E .),whose extensive clinical experience taught him the seriousness of biliary tract disease,recorded that ‘‘in case of jaundice,it is a bad sign when the liver becomes hard’’(Fig.1).Arthur Weigle suggested that the terminal illness of Alexander the Great (356–323B .C .E .),which led to peritonitis secondary to perforation or to associated pan-creatitis at the young age of 33,was compatible with acute obstructive cholecystitis [3,4].Learning about the anatomy and surgery of the biliary tractThroughout the years numerous great scientists have done work that provided information concerning the anatomy and surgery of the biliary tract.Their names are used eponymously in the description of biliary tract surgery:The renaissance in anatomy began with Leonardo da Vinci and Michelangelo.Anatomy became a true science with Andreas Vesalius of Padua (A .D .1514–1564)(Fig.2).His epitome of seven books (Atlas Compendium)corrected errors of Galen.Vesalius described gallstones and their consequences [5].Francis Glisson (1597–1677)was the first to thoroughly describe the distribution of a common capsule investing the hepatic artery,portal vein,and the bile duct.Glisson wasS.Yannos ÁF.EvangelosFirst Department of Surgery,Laikon Teaching Hospital,University of Athens Medical School,Athens,Greece e-mail:yannos_s@ F.Evangelose-mail:felek@med.uoa.grP.Athanasios ÁC.Christos (&)Division of HPB,Department of Surgery,Nicosia GeneralHospital,215Nicosia-Limassol Old Road,2029Nicosia,Cyprus e-mail:christofchris@ P.Athanasiose-mail:thpetrou@World J SurgDOI10.1007/s00268-013-1960-6also the first to describe a sphincteric mechanism around the orifice of the common duct [6–8].In 1720Abraham Vater (Fig.3)described the tubercule or diverticulum as ‘‘those double ducts (bile and pancreatic ducts)that come together in no single combination.’’Vater described not an ampulla but an elevation of the mucosa in the duodenum.He actually described the first case of an ampulla with two orifices [9,10].Theodore Kocher (1841–1915)was a pioneer in abdominal surgery,and he advocated the use of a subcostal incision.He published a procedure for sphincteroplasty and standardized a technique in 1903for mobilization of the duodenum (Fig.4).The latter method,known as Kocher’s maneuver,was originally developed to expedite gastrodu-odenostomy but has since been used for biliary and pan-creatic operative procedures[11–15].Fig.2Anatomical figure,from Andreas Vesalius (from http://anato ;acknowledgments to Daniel Garrison from The Fabric of the Human Body,Karger Publishers,Basel,Switzerland).Adapted from /about.html under terms and copyright says ‘‘Daniel Garrison retains the copyright to the digitized image from the Vesaliustext’’Fig.3Abraham Vater (from ;original uploader was Torsten Scheleese at de.wikipedia).Adapted from http://en./wiki/File:Abraham-Vater.jpgFig.4Theodore Kocher (from ).Adapted from /wiki/File:Emil_Theodor_Kocher.jpg#globalusageFig.1Hippocrates (engraving by Peter Paul Rubens,1638.Courtesy of the National Library of Medicine;from http//:).Adapted from /wiki/File:Hippo crates_rubens.jpgWorld J SurgThe biliary tract was Ludwig Courvoisier’s prime interest (Fig.5),and he wrote numerous articles on dis-eases and management of biliary tract disorders.He was the first to describe the removal of a stone from the com-mon bile duct [16,17].In his monograph published in 1890he discussed different types of ductal obstruction,and in a review of 187cases he described that in the presence of an enlarged gallbladder which is nontender and accompanied with mild jaundice,the cause of the enlargement is unlikely to be gallstones.From this article arose the eponym Courvoisier’s gallbladder or Courvoisier’s law [18,19].Morison’s pouch,described in 1894,was used for drainage in biliary surgery.The pouch is in the hepatorenal space,below the lower pole of the right kidney,after reflection of the hepatic flexure.James Rutherford Morison [20–24]was a practical surgeon and a beautiful but fearless operator.Jean-Franc ¸ois Calot is remembered by general surgeons for his doctorate thesis written in Paris in 1890,‘‘De La Cholecystectomie,’’in which he described the anatomic and technical aspects of cholecystectomy in great detail.When working around the cystic duct one is ‘‘in the more delicate part of the operation.’’He described an isosceles triangle with the base the common hepatic duct,the inferior edge the cystic duct,and the superior border the cysticartery (Fig.6).Calot’s triangle has since been enlarged,with the edge of the liver as the superior border [25–27].Ruggero Oddi (1864–1913)was the first to measure the resistance of the sphincter and to demonstrate that removal of the gallbladder causes dilation of the bile ducts,which has now been shown to be a non-physiologic response (Fig.7)[28–30].The first surgeriesPrior to the fifteenth century physicians were unfamiliar with gallbladder diseases.It was in that era thatphysiciansFig.5Ludwig Courvoisier (from ,Wellcome Library,London).Adapted from /indexplus/result.html?*sform=wellcomeimages&_IXACTION_=query&%24%3Dtoday=&_IXFIRST_=1&%3Did_ref=M0010712&_IXSPFX_=templates/t&_IXFPFX_=templates/t&_IXMAXHITS_=1Fig.6Calot’s triangle (from J Minim Access Surg 2005June;1(2):53–58).Adapted from /pmc/articles/PMC3004105/Fig.7Ruggero Oddi (from ,Jeffrey P.Kanne et al.,March 2006,RadioGraphics 26:465–480).Adapted from /content/26/2/465/F11.expansion.htmlWorld J Surgstarted to recognize gallstone diseases,and they did an excellent job,specifically in thefield of hepatobiliary surgery research,recognizing obstructive jaundice and its clinical manifestations[31–33].Thefirst interaction of the gallstone and surgery was accidental.In1687,Stalpert von der Wiel opened a puru-lent upper abdominal abscess in a patient with a long his-tory of abdominal pain and found gallstones[34,35].Acknowledgment must be given,however,to Jean-Louis Petit as the founder of gallbladder surgery.In1733, this Parisian surgeon noted gallstone abscesses and sug-gested that when a reddening of the abdominal skin occurred in association with biliary colic,the surgeon should lance the area,remove the gallstones,and leave a gallfistula.In1743,he successfully carried out such an operation.On July15,1867,in Indianapolis,Indiana,John Bobbs was searching for an ovarian cyst in a thirty-year-old woman with a four-year history of biliary colic.He found an inflamed adhered sac that contained,much to his sur-prise,‘‘several solid bodies about the size of ordinary rifle bullets.’’He then closed the cholecystotomy incision and placed the gallbladder near the undersurface of the abdominal incision.The patient recovered and outlived Doctor Bobbs[36,37].Marion Sims(Fig.8)must be given the credit for designing,perfecting,and performing thefirst cholecys-tostomy.In April18,1878,Sims in thatfirst such opera-tion,he removed multiple stones and bile and sewed the open gallbladder to the corner of the abdominal incision. Eight days postoperatively,the patient died of massive internal hemorrhage.At autopsy examination,16gall-stones were found,ranging in size from a pea to a pigeon egg.Only2months had passed when Theodor Kocherfirst, successful drained a gallbladder empyaema.[38,39].In1881,William S.Halsted performed hisfirst biliary operation on his elderly mother,who was desperately ill with jaundice,fever,and an abdominal mass.At her home in Albany,New York,he incised the mass,releasing pus and gallstones from the gallbladder[40].While others were pursuing the construction of gall-bladderfistulas and direct removal of gallstones,Carl Langenbuch of Berlin was preparing himself to completely remove the organ,for he had observed that simple drainage and stone removal gave only temporary relief(Fig.9). Because stones were known to recur in the gallbladder,he stated‘‘they[other surgeons]have busied themselves with the product of the disease not the disease itself.’’Langen-buch,who at27years of age had been appointed Director of the Lazarus Hospital in Berlin,developed the technique for cholecystectomy through several years of cadaver dis-section.On July15,1882,he successfully removed the gallbladder of a43-year-old man who had suffered from biliary colic for16years,thereby performing the first successful ngenbuch foundtwo Fig.8Marion Sims(from ,Engraved by R.O’Brien,from /images/B23841).Adapted from/wiki/File:James_Marion_Sims.jpgFig.9Carl Langenbuch(from ,ClendeningLibrary Portrait Collection).Adapted from http://commons.wikimedia.org/wiki/File:Carl_Langenbuch.jpgWorld J Surgcholesterol stones and a chronically inflamed and thickened gallbladder.The next day the patient was afebrile,pain-free,and smoked a cigar.He left the hospital6weeks later, gaining weight and without pain[41].Early twentieth centuryIn the early years of the twentieth century,biliary opera-tions were hazardous.For example,of100cholecystecto-mies reported in1897,the mortality was20%.No specific diagnostic tests for biliary tract disease were available,and prominent clear-cut clinical signs,such as tender mass in the right upper quadrant with fever,and commonly jaun-dice,had to be present before the idea of an operation on the gallbladder could be entertained[42].In1924Evarts Graham and Warren Cole discovered the diagnostic procedure of cholecystography,and in1931 Pablo Mirizzi from Argentina(Fig.10)performed thefirst operative cholangiography[43].Endoscopic retrograde cholangiography owes its origin to the persistent pioneer-ing efforts of Rudolph Schindler,who worked with the semirigid gastroscope.However,in1968,a group of phy-sicians published thefirst report documenting the initial clinical application of endoscopic retrograde cholangio-pancreatography(ERCP).These physicians included W.S.McCune and P.E.Shorb from the George Washington University Medical Center(GW)and H.Moscovitz,who practiced mainly at the Washington(DC)Hospital Center. At present,when common bile duct(CBD)stones are suspected preoperatively instead of requesting an ERCP, which in many cases is negative,magnetic resonance cholangiopancreatography(MRCP),when available,is a quick,noninvasive method that can clearly rule out the presence of CBD obstruction and thus avoid unnecessary ERCP or CBD exploration[44–47].One of the early problems of biliary surgery that Halsted addressed pertained to methods of closing or draining the common duct after exploration.A variety of tubes were devised for common duct drainage,but the rubber T-tube introduced by the German surgeon Hans Kehr in the early twentieth century has proved to be the one universally adopted(Fig.11)[48].In1910Hans Christian Jacobaeus(Fig.12)coined the term‘‘laparoscopy.’’The thought processes behind this descriptor was a procedure that would allow the surgeon to obtain details of the body cavities and to see important striking features of the body by looking inside without practically opening the patient.It evolved into an effective diagnostic and therapeutic tool in surgery[49–52].Further developments in the early years of the century included the adoption of placing the patient in the Tren-delenburg position by Severin Nordentoeft in Copenhagen (1912),the use of carbon dioxide for insufflationby Fig.10Pablo Mirizzi(from World J Gastroenterol September14;18(34):4639–4650,2012).Adapted from /1007-9327/full/v18/i34/4639.htmFig.11Hans Kehr(from ,reprinted in:Klimpel V.Stammt das‘‘Kehrsche Zeichen’’von Hans Kehr.Chirurg75(1):80–83,2004).Adapted from /wiki/File:Kehr.JPGWorld J SurgC.L.Zollikoffer in Switzerland (1924),and the introduc-tion by Janos Veress in Budapest (1938)of the modern spring-loaded needle,which he devised to induce pneu-mothorax in the treatment of pulmonary tuberculosis [53–56].Modern timesIn 1987,Philip Mouret,a French surgeon in Lyon,per-formed the first video-laparoscopic cholecystectomy.This new technique was introduced in the United States in 1988by Barry McKiernan and William Saye in Marietta,Georgia,and shortly thereafter by Eddie J.Reddick and Douglas O.Olsen in Nashville.During the period 1989–1991it is estimated that approximately 20,000American general surgeons received training in laparo-scopic techniques.Today,more than 600,000cholecys-tectomies are performed annually in the United States,most of them laparoscopically [57–59].The advantages of laparoscopic cholecystectomy over open cholecystectomy were immediately appreciated,including earlier return of bowel function,less postoperative pain,improved cosme-sis,shorter length of hospital stay,earlier return to full activity,and decreased overall cost [60–62].When the technique was first developed it was thought to be inadvisable in patients who were pregnant,grossly obese,or who had just recovered from acute pancreatitis.Ideas have changed,and these conditions are now consid-ered ideal for the laparoscopic technique.Many surgeons with a keen interest in laparoscopic surgery will first con-sider the laparoscopic approach for all patients who require a cholecystectomy.Attempts have been made to identify patients who are unsuitable for the procedure by preoper-ative ultrasonography:it is known that in patients with a thick-walled gallbladder,a large stone,or evidence of inflammation in Hartmann’s pouch,or a localized abscess the procedure will prove difficult,but the laparoscopic approach can still be undertaken in most of these patients.The prime indication for cholecystectomy is biliary colic,with its characteristic and well-defined pain.Acute cholecystitis,with its complications,is an urgent indication for cholecystectomy.Indeed,an attack of gallstone-related disease necessitating admission to the hospital is an indi-cation for cholecystectomy during that admission,or soon thereafter,to avoid the development of more severe symptoms or complications.Jaundice caused by gallstones is a further indication for cholecystectomy after the gall-stones have been treated endoscopically,except in elderly patients,for whom the endoscopic procedure is sufficient in 85%of cases.ConclusionsEvery surgeon who operates in the abdomen should be highly trained in the field of biliary surgery.After all,cholecystectomy is the most common operative procedure performed on the biliary tract and the second most common major operation performed today.The day of the large cholecystectomy scar with its subsequent incisional hernia has gone.As surgeons,a review of the important devel-opments in surgery for treatment of biliary tract diseases throughout history allows us to appreciate the changing nature of our profession.We must recognize the work of the innovators who contributed so much to our present understanding.Moreover,we should keep an open mind for things to come so we can choose the best way to help our patients with minimal risk and reduced cost.References1.Glenn F (1971)Biliary tract disease since antiquity.Bull NY Acad Med 47:3292.Praderi R (1982)One 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