How I do it: laparoscopic treatment of common bile duct stones
The standard treatment for patients with symptomatic gallstones is laparoscopic cholecystectomy (LC). In patients undergoing LC the prevalence of common bile duct (CBD) stones ranges between 8% and 15% and it increases with advancing age, reaching up to 60% in elderly patients. Every patient who is candidate for LC should be evaluated for the presence of CBD stones and these should be treated if the diagnosis is confirmed. In the literature, the procedure of choice for CBD stones treatment is still debated. In many centers, pre- or postoperative endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) and LC (two-stage endo-laparoscopic management) is considered standard practice instead of open choledocholithotomy and cholecystectomy. Laparoscopic single-stage management of gallstones and CBD stones has demonstrated equivalent outcomes to the two-stage endo-laparoscopic approach in randomized controlled trials but with shorter hospital stay and fewer interventions. Moreover, the two-stage endo-laparoscopic management of CBD stones and gallstones may be associated with a higher additional procedures rate, and possibly increased costs, as compared to single-stage laparoscopic management. Another option is single-stage endo-laparoscopic management of gallstones and CBD stones, performing ERCP/ES during the same LC anesthesia (so called, “Rendez-Vous” procedure). Excluding patients with cholangitis, who should be managed by emergency ERCP with ES and stones removal, in the elective setting the ultimate choice for one procedure or the other largely depends on the local resources and expertise that are available in the individual center, notwithstanding the scientific evidence in favour of single-stage laparoscopic management. The authors report the surgical techniques that they follow during LC for CBD exploration and stones’ removal by laparoscopic trans-cystic or choledochotomy approach.