Ductal stones: pathology, clinical manifestations, laparoscopic extraction techniques, and complications

Laparoscopic treatment of ductal calculi in experienced hands is more successful and incurs a shorter hospital stay and overall costs than current orthodox two-stage management (endoscopic stone extraction followed by cholecystectomy). The results of large series of laparoscopic ductal stone clearance report a median success rate of 90%, a mortality under 1%, and a missed stone rate of 0.8% to 4%. Thus the case for routine preoperative endoscopic stone extraction is no longer sustainable and this management option should be reserved for patients with cholangitis, severe gallstone-associated pancreatitis, and for patients considered unfit for surgery and general anesthesia. The remaining issues concern standardization of the techniques of laparoscopic ductal stone extraction and the intraoperative management algorithm with agreed indications for transcystic extraction versus direct common bile duct (CBD) exploration. Narrowed bile ducts should not be explored directly, and if the transcystic laparoscopic approach fails in these cases, endoscopic extraction is the safest option, either at the time of surgery under the same anesthetic or during the postoperative period. The insertion of a T-tube after direct common duct exploration detracts considerably from the benefits of the laparoscopic approach, and primary closure with either a cystic duct drainage cannula or by means of a temporary endobiliary stent is recommended.