Common bile duct (CBD) stones, also known as choledocholithiasis, are gallstones that migrate from the gallbladder into the common bile duct. They can cause biliary obstruction, jaundice, cholangitis, and pancreatitis if untreated. Traditionally, open exploration of the CBD or endoscopic retrograde cholangiopancreatography (ERCP) has been used to manage these stones. However, with the advancement of minimally invasive surgery, laparoscopic management of CBD stones has become an increasingly popular and effective option.

Laparoscopy provides excellent visualization, reduced morbidity, shorter hospital stays, and quicker recovery, making it a reliable choice in appropriately selected patients.

Indications for Laparoscopic CBD Exploration

Laparoscopic management is considered in the following situations:

Symptomatic choledocholithiasis with or without jaundice.

Acute cholangitis requiring definitive treatment.

CBD stones detected incidentally during laparoscopic cholecystectomy.

Stones not amenable to ERCP or after failed ERCP.

Patients who require single-stage management of gallstones and CBD stones.

Preoperative Evaluation

According to best practices, thorough evaluation is essential before surgery.

Clinical features: Jaundice, abdominal pain, fever (Charcot’s triad in cholangitis).

Laboratory tests: Elevated bilirubin, alkaline phosphatase, gamma-GT, leukocytosis.

Imaging studies:

Ultrasound (USG) – identifies dilated CBD and gallstones.

MRCP (Magnetic Resonance Cholangiopancreatography) – non-invasive gold standard for stone detection.

Endoscopic Ultrasound (EUS) – high accuracy for small stones.

Intraoperative cholangiography (IOC) – confirms CBD stone presence during surgery.

Laparoscopic Techniques for CBD Stone Management

Dr. R. K. Mishra and other laparoscopic experts describe two main approaches for laparoscopic CBD exploration:

Transcystic CBD Exploration

This technique uses the cystic duct as a pathway to access the CBD.

Steps:

Standard laparoscopic cholecystectomy ports are placed.

The cystic duct is identified and dilated.

A choledochoscope or guidewire is introduced through the cystic duct into the CBD.

Stones are extracted using baskets, balloons, or flushing.

After clearance, the cystic duct is clipped and divided.

Advantages:

Minimally invasive with less trauma.

Suitable for small stones (<6 mm).

Shorter operative time.

Limitations:

Not feasible in cases of multiple, large, or impacted stones.

Narrow or tortuous cystic duct limits access.

2. Transcholedochal CBD Exploration

This involves a direct incision into the CBD for stone retrieval.

Steps:

A longitudinal choledochotomy is made in the supraduodenal CBD.

Stones are retrieved using a choledochoscope, Dormia basket, or Fogarty balloon.

Thorough clearance of the duct is confirmed.

The CBD is closed either primarily (T-tube-free repair) or over a T-tube for drainage.

Advantages:

Allows removal of large, multiple, or impacted stones.

Direct visualization ensures complete clearance.

Disadvantages:

Higher risk of bile leak and stricture formation.

Requires advanced laparoscopic skill.

Role of Intraoperative Choledochoscopy

Laparoscopic choledochoscopy plays a crucial role in ensuring stone clearance. It allows direct visualization of the biliary tree, confirms ductal clearance, and avoids retained stones. Flexible and rigid choledochoscopes with working channels permit the use of baskets or lithotripsy devices for stone fragmentation.

Postoperative Management

Drainage: A drain may be placed to monitor for bile leakage.

Antibiotics: Given in cases of cholangitis or contamination.

Monitoring: Serial liver function tests and imaging if complications suspected.

Recovery: Patients are usually discharged within 3–5 days after laparoscopic CBD exploration.

Complications

Although safe and effective, laparoscopic CBD exploration carries certain risks:

Bile leak from cystic duct stump or choledochotomy closure.

Retained stones due to incomplete clearance.

Biliary stricture formation.

Pancreatitis if pancreatic duct is inadvertently manipulated.

Infection and cholangitis.

With proper technique and intraoperative choledochoscopy, complication rates remain low.

Outcomes and Advantages

Laparoscopic CBD exploration has been shown to have outcomes comparable to ERCP with added benefits:

Single-stage procedure – both cholecystectomy and CBD clearance done in one sitting.

Avoids ERCP-related complications like pancreatitis, bleeding, or perforation.

High success rates – duct clearance achieved in 90–95% of cases.

Reduced hospital stay compared to staged procedures (ERCP followed by laparoscopic cholecystectomy).

Improved patient satisfaction due to faster recovery and minimal scarring.

Conclusion

Laparoscopic management of CBD stones represents a significant advancement in hepatobiliary surgery. Both transcystic and transcholedochal approaches are effective, with selection depending on stone size, number, and anatomical factors. The use of laparoscopic choledochoscopy ensures complete ductal clearance and reduces the risk of retained stones.

When performed by skilled surgeons, laparoscopic CBD exploration provides a safe, effective, and minimally invasive alternative to ERCP and open surgery. It allows a single-stage treatment for gallstones and CBD stones, minimizing patient morbidity and improving overall outcomes.