Choledocholithiasis: Evolving intraoperative strategies

In the era of open cholecystectomy, common bile duct stones were approached by traditional choledocholithotomy, Retained or recurrent stones discovere d after cholecystectomy were approached by endoscopic extraction techniques or repeat surgery. With the advent of laparoscopic cholecystectomy, the ap proach to choledocholithiasis became more problematic as techniques for lap aroscopic extraction were rudimentary. Preoperative endoscopic retrograde c holangiopancreatography rapidly became an adjunct to laparoscopic cholecyst ectomy when common duct stones were likely, Experience, however, revealed t hat many of these procedures were unnecessary. With developing sophisticati on of laparoscopic techniques, a variety of approaches to common duct stone s developed. These included: transcystic extraction, direct laparoscopic ch oledocholithotomy, intraoperative endoscopic retrograde cholangiopancreatog raphy, antegrade sphincterotomy, and transcystic placement of a common duct stent with subsequent endoscopic sphincterotomy and stone extraction. It i s the purpose of this article to define the current role of each of these m ethods in the laparoscopic approach to choledocholithiasis.