Surgical strategies for challenging common bile duct stones in the endoscopic era: A comprehensive review of current evidence

Abstract

While endoscopic retrograde cholangiopancreatography (ERCP) remains the primary treatment modality for common bile duct stones (CBDS) or choledocholithiasis due to advancements in instruments, surgical intervention, known as common bile duct exploration (CBDE), is still necessary in cases of difficult CBDS, failed endoscopic treatment, or altered anatomy. Recent evidence also supports CBDE in patients requesting single-step cholecystectomy and bile duct stone removal with comparable outcomes. This review elucidates relevant clinical anatomy, selection indications, and outcomes to enhance surgical understanding. The selection between trans-cystic (TC) vs trans-choledochal (TD) approaches is described, along with stone removal techniques and ductal closure. Detailed surgical techniques and strategies for both the TC and TD approaches, including instrument selection, is also provided. Additionally, this review comprehensively addresses operation-specific complications such as bile leakage, stricture, and entrapment, and focuses on preventive measures and treatment strategies. This review aims to optimize the management of CBDS through laparoscopic CBDE, with the goal of improving patient outcomes and minimizing risks.

Keywords: Choledocholithiasis; Common bile duct stone; Difficult common bile duct stone; Common bile duct exploration; Laparoscopic common bile duct exploration

Core Tip: Although the endoscopic-first approach is the most common for common bile duct stones (CBDS) treatment, surgical management remains crucial for subsequent cholecystectomy and additional CBDS removal in cases of failed endoscopy or surgical altered anatomy. Single-step common bile duct exploration offers non-inferior outcomes and may even advantageously reduce the number of hospital admissions. Proper selection between the trans-cystic and trans-choledochal approach is essential, and mastering both techniques through practice and rehearsal is necessary. Diligent attention to surgical anatomy and every step of the procedure can help prevent and reduce specific postoperative complications.