Open Operations on the Bile Duct for Stones

The management of bile duct stones attained an acceptable plateau of development in the late 1980s, with the majority of bile duct stones removed by open exploration and the difficult stone delegated to the endoscopist. This situation was disturbed by the introduction of laparoscopic cholecystectomy; it was no longer straightforward policy to explore the bile duct, and alternatives had to be considered. Open operation may now be required (1) if an unexpected stone is found during laparoscopic cholecystectomy with a small cystic duct, (2) if laparoscopic choledochotomy is undertaken and technical problems are encountered, (3) when stones in the duct cannot be removed endoscopically, (4) by preference of the surgeon on the basis of similar risk factors, (5) in the sick patient with cholangitis, and (6) after technical failure of endoscopic sphincterotomy. The technique of open operation must be meticulous and should preferably be performed with choledochoscopy either peroperatively or postoperatively. The open technique for bile duct exploration continues to have a role, and when performed expertly, its morbidity and mortality will be similar to the endoscopic and laparoscopic techniques.