Through the scope, through the years: declining trends in laparoscopic common bile duct exploration

Laparoscopic common bile duct exploration (LCBDE) remains an effective single-stage strategy for choledocholithiasis, but declining utilization has raised concerns about diminishing operative experience and training exposure among contemporary surgeons. We evaluated institutional trends in LCBDE, intraoperative cholangiography (IOC), and resident participation and identified predictors of successful duct clearance.

This retrospective single-center cohort study (2012-2021) included adults undergoing laparoscopic or robotic cholecystectomy. Patients were grouped as single-stage LCBDE with cholecystectomy or two-stage management with ERCP and endoscopic sphincterotomy followed by cholecystectomy. Cases were identified using CPT and ICD procedure codes cross-referenced with operating room logs. Data were abstracted from the electronic medical record. Primary outcomes were temporal trends in LCBDE, IOC utilization, and resident participation. Secondary outcomes were predictors of successful LCBDE.

LCBDE succeeded in 240/291 cases (82.4%). Failures occurred exclusively during transcystic exploration, most commonly due to an inability to cannulate the cystic duct (43%). Median length of stay was shorter after successful LCBDE (1 vs 3 days, p < 0.001). Surgeons in successful cases had greater experience (median 17.5 vs 12.9 years, p = 0.03). On multivariable analysis, surgeon experience independently predicted success (OR 1.04 per year, 95% CI 1.004-1.078), whereas surgeon specialty was not significant after adjustment. Of 303 LCBDE patients, 291 met inclusion criteria; among 339 two-stage patients, 257 met inclusion criteria. Institutionally, annual LCBDE volume declined (trend p < 0.05), IOC utilization decreased (66% in 2018 to 54% in 2021), and resident involvement fell (91.8% in 2014 to 69.6% in 2021), with per-resident exposure declining from 2.2 to 0.9 cases per year.

LCBDE achieves high duct-clearance rates and shorter hospitalization when successful. Surgeon experience, rather than specialty, independently predicts success, underscoring a clinically meaningful learning curve. Declines in LCBDE volume, IOC utilization, and resident exposure highlight the need for training strategies including simulation, standardized workflows, and improved case access to preserve competency.