Management of common bile duct stones in the era of laparoscopic surgery.

In the era of laparoscopic surgery, the best approach for common bile duct (CBD) stones remains a matter of debate. When CBD exploration was performed by laparotomy, prospective randomized trials did not show the superiority of preoperative endoscopic sphincterotomy (ES) over CBD surgery for stones.1,2 The advent of laparoscopic surgery led to a dramatic change in the approach of CBD stones treatment. Indeed, because of an obvious lack of expertise in laparoscopic surgery, surgeons elected to detect and treat preoperatively CBD stones by ES since they considered laparoscopic CBD exploration as an unduly, complex, and demanding procedure. It is worth mentioning that this approach requires several sessions of anesthesia and cumulates the risk of ES and laparoscopic cholecystectomy. In addition, it increases the cost.3,4 About 15 years after the introduction of laparoscopic cholecystectomy, one has to wonder whether or not this policy should be still applied. Indeed, in patients fit for surgery, laparoscopic CBD stones extraction seems to be superior to the association of ES and laparoscopic cholecystectomy.5 The reported incidence of CBD stones found during laparoscopic cholecystectomy ranges from 3 to 10%.6−8 It is unclear whether an asymptomatic choledocholithiasis requires treatment. Furthermore, it is well established that small stonesmay pass through the ampulla of Vater.9 Moreover, it is not clear what stone size precludes transpapillary migration into the duodenum nor which criteria will predict complications of pancreatitis or cholangitis if CBD stones are not treated. Therefore, it is generally recommended to treat CBD stones whenever detected. Theoretically, CBD stones can be treated with or without cholecystectomy. Moreover, if cholecystectomy is performed this could be done before, during or after CBD stones extraction. The purpose of this chapter is to try to clarify these different points.