Evolving management of common bile duct stones in the laparoscopic era

The role of laparoscopic duct exploration in the management of common bile duct (CBD) stones is unclear. The aim of this study is to audit the current management of choledocholithiasis in our unit and to report on the introduction of laparoscopic management, comparing it with established techniques. Over a 5-year period, 173 patients presented with CBD stones. In 105 (61%) patients, primary management of choledocholithiasis was by endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) which was successful in 85 (81%) cases. Of the 20 patients with retained stones following ES, 18 underwent subsequent surgical exploration. Fifty (29%) patients underwent open CBD exploration as a primary treatment, resulting in complete clearance in 43 (86%) cases. Retained CBD calculi following open surgery occurred in seven cases and were ultimately treated by post-operative ES (n = 5), and observation (n = 2). Eighteen (10%) patients underwent primary laparoscopic CBD exploration. Four cases were converted to open surgery. Of the 14 completed laparoscopic duct explorations, 12 (86%) were successful. Two patients had retained stones, requiring secondary treatment with ERCP and ES. There was no mortality in the entire series. The complication rate was 12.4% with ERCP, 14% with open surgery, and zero with laparoscopic CBD exploration. There was no significant difference in hospital stay between groups. We conclude that the management of choledocholithiasis is in evolution, and early results suggest that laparoscopic CBD exploration compares favourably with established open surgical and endoscopic methods.