Common Bile Duct Stones: Endoscopic Extraction or Laparoscopic Management

Abstract

Starting in the early 1990s, laparoscopic cholecystectomy (LC) has become the treatment of choice for patients with symptomatic gallbladder stones, and more than 85% of all patients are now treated this way. Among these patients a proportion of 7–20% suffer from choledocholithiasis.¹ The preoperative clinical and laboratory evaluation of possibly coexisting common bile duct (CBD) pathology is therefore important for making the appropriate management decision. The management of CBD stones has changed considerably. Therapeutic endoscopy has become firmly established as the most effective minimally invasive approach to CBD stones, and it is now preferable to surgery in the majority of patients. Laparoscopic CBD exploration was the logical extension of laparoscopic cholecystectomy, as experience and laparoscopic technology has grown. The advent of laparoscopic techniques for CBD stone treatment has introduced the alternative of a single-stage treatment for these patients, and it has given rise to debate regarding the optimal management of choledocholithiasis. Laparoscopic surgery has improved the management of gallbladder stones in many aspects, and, after the extension of laparoscopic techniques to common duct pathology, many questions have arisen regarding the proper CBD stone treatment. It is not clear now whether the management of these patients should be conducted in two stages [preoperative endoscopic retrograde cholangiography (ERC) and endoscopic sphincterotomy (EST) followed by LC], or as a one-stage surgical procedure with ductal stone extraction being performed at the time of LC. This chapter will focus on some of the controversies in the management of ductal stones in patients undergoing laparoscopic cholecystectomy, and an attempt will be made to give some guidelines to the optimal therapy of patients with gallbladder and common duct stones in the era of laparoscopic surgery.