Choledocholithiasis: Evolving Intraoperative Strategies

In the era of open cholecystectomy, common bile duct stones were approached by traditional choledocholithotomy. Retained or recurrent stones discovered after cholecystectomy were approached by endoscopic extraction techniques or repeat surgery. With the advent of laparoscopic cholecystectomy, the approach to choledocholithiasis became more problematic as techniques for laparoscopic extraction were rudimentary. Preoperative endoscopic retrograde cholangiopancreatography rapidly became an adjunct to laparoscopic cholecystectomy when common duct stones were likely. Experience, however, revealed that many of these procedures were unnecessary. With developing sophistication of laparoscopic techniques, a variety of approaches to common duct stones developed. These included: transcystic extraction, direct laparoscopic choledocholithotomy, intraoperative endoscopic retrograde cholangiopancreatography, antegrade sphincterotomy, and transcystic placement of a common duct stent with subsequent endoscopic sphincterotomy and stone extraction. It is the purpose of this article to define the current role of each of these methods in the laparoscopic approach to choledocholithiasis.