Laparoscopic approaches to the common bile duct stone: transcystic bile duct exploration, choledochotomy and stone...

It has been illustrated that a convergence of new technologies, including advanced laparoscopic techniques, flexible video endoscopy, coaxial balloon dilators and biliary lithotripsy, has allowed the modern laparoscopic surgeon to address a pressing issue: how to deal with choledocholithiasis. A variety of techniques and methods have been described; each has their advocates, philosophical advantages and potential drawbacks. The definitive decision as to which technique is the best awaits the results of future prospective studies. Until then, the three techniques outlined will allow the majority of surgeons to extend the advantages of minimally invasive surgery to patients with choledocholithiasis. There is no doubt that this is desirable. These procedures, however, are not without their failure rate and complications, and they remain technically demanding. Increased education and training of surgeons is needed and further improvement of existing technology is demanded. This includes improved fibreoptic choledochoscopes with better optics, more flexibility and larger working channels; better stone baskets and better mechanical graspers, and safer and more effective stone lithotriptors. Other questions remain unanswered, such as the relative and absolute contraindications to performing laparoscopic common duct explorations. Can patients with multiple common duct stones or very small ducts be safely handled using these methods? Is there a size of common duct stone that is safe to leave behind, and are there safe antegrade methods of treating distal duct stenosis? The new interest in avoiding the placement of T-tubes for common duct drainage also needs close scrutiny. All these questions need well-constructed studies to answer them; but in the meantime, laparoscopic common duct exploration is undoubtedly here to stay, and this new approach to an old problem is inducing biliary surgeons to question many traditionally held dicta, which can in the long run only be in the patients' best interest.