Techniques and Cost of Common Bile Duct Exploration

The introduction of laparoscopic techniques to treat biliary tract disease in the last decade heralded the beginning of a new age of surgery where strong emphasis is placed not only on the efficacy of the operation, but at least as importantly on the "side effects" of surgical intervention. Thus, the focus has recently centered on the application of minimally invasive and minimally damaging techniques to perform operations that heretofore had required laparotomy. Laparoscopic cholecystectomy (LC) itself is an excellent example of a procedure that produces an equivalent disease-related treatment endpoint, without the morbidity of previous "open" techniques. Laparoscopic treatment of common bile duct stones, while technically much more difficult than cholecystectomy, offers the same minimally invasive benefits to the patient without the necessity of laparotomy or secondary procedures such as endoscopic retrograde choledocholithotomy or sphincterotomy. Numerous techniques for laparoscopic common bile duct exploration (LCDE) have been developed. Each of them accesses the stones by one of two routes: through the cystic duct or through a choledochotomy. Both approaches are associated with equivalent success rates in removing stones, but the transcystic approach has the added benefit of being truly minimally invasive, as compared with choledochotomy. This report reviews the current state of the art of the transcystic approach to the laparoscopic treatment of choledocholithiasis.