Most surgeons now accept that injuries to the bile duct occur more commonly with laparoscopic cholecystectomy than with the old style, open operation. And because the injuries occur higher up in the bile duct, they may be harder to repair (BMJ, 1996; 308: 928).

In Ontario, Canada, where 86 per cent of gall bladder operations are performed laparoscopically, the number of bile duct injuries has increased by 305 per cent (Lancet, February 24, 1996).

Besides bile duct injuries, there is also the, admitedly rare, possibility that some gallstones "leak" out and are retained in the tissue after surgery, as happened in one case (J Royal College Surg Edinburgh, 1993; 38: 353). Patients have also been pierced by surgical instruments (Surgery, 1991; 110: 769-77). There also may be an increased risk of thromboembolism in patients undergoing laparoscopic gall bladder operations (BMJ, 1993; 306: 518-9), and spreading cancer, if it is present (N Eng J Med, 1991; 325: 1316-7).

The popularity of laparoscopy operations is also having another effect. Surgeons in Bristol, reviewing the gall bladder operations they'd done in the three years up to April 1994, saw they'd carried out 578 laparoscopic cholecystectomies and 35 open operations. Fourteen trainee surgeons had performed only 16 open cholecystectomies and assisted at nineteen. Trainee surgeons rarely see an open operation, let alone become familiar with the different techniques required (Ann Royal Coll of Surg Eng, 1995; 77: 256-8).

This is devastating news. The obvious disadvantage of laparoscopic cholecysectomy therefore is that its wide adoption could lead to a new generation of surgeons emerging who are not experienced in open surgery to use it when needed (BMJ, 1992; 304: 559-60).

Extracorporeal shockwave lithotripsy (ESWL), the much ballyhooed alternative to surgery, where the gallstones are literally pounded into submission by a series of sound waves, has also been criticized because it can result in kidney damage and raises blood pressure, which is more pronounced if stones are close to, or in, the kidney (Lancet, 1993; 341: 1151-2).

The procedure also leaves gallstone residue in the bile duct which then provides a home for bacteria (JAMA, 1994; 272: 1643).

Over the last 10 years, ESWL has been hailed as a technique that would revolutionize the medical management of kidney stones, as well as gallstones. However, recent studies show that most patients experience internal bleeding, ranging from tiny hemorrhage to major bleeding that requires transfusion.

This bleeding also seems to change the dynamics of the blood in the kidney, causing hypertension in up to 8 per cent of patients (RH Heptinstall, Pathology of the Kidney; Little, Brown, 1992). The extent of damage appears dependent upon the dose of shock waves used (see also WDDTY; vol 5 no 11).

But in most cases, you shouldn't have to resort to surgery. According to WDDTY Alternative columnist Harald Gaier, gallstones can be made up from, very rarely, either pure cholesterol; pure pigment (calcium bilirubinate); a mixture of cholesterol and its derivatives, along with varying amounts of bile salts, bile pigments and inorganic salts of calcium; and stones which are composed entirely of minerals.

Recent studies have shown that nearly 80 per cent of sufferers have stones of the mixed variety. The remaining 20 per cent of the stones are made up entirely of minerals, mainly calcium salts (Ann Clin Lab Sci, 1984; 14: 243-51). This is good news because only the solid mineral variety require surgery. An x-ray of the gall bladder can tell you the type of stone (only the mineral ones will show up as solid).