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Review
. 2024 Jun 16;16(6):305-317.
doi: 10.4253/wjge.v16.i6.305.

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

Tharathorn Suwatthanarak  1   2 , Vitoon Chinswangwatanakul  1 , Asada Methasate  1 , Chainarong Phalanusitthepha  1 , Minoru Tanabe  3 , Keiichi Akita  4 , Thawatchai Akaraviputh  5
Affiliations
Review

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

Tharathorn Suwatthanarak et al. World J Gastrointest Endosc. .

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 exploration; Common bile duct stone; Difficult common bile duct stone; Laparoscopic common bile duct exploration.

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Conflict of interest statement

Conflict-of-interest statement: Authors declare no conflict of interests for this article.

Figures

Figure 1
Figure 1
Common anatomy of portal triad, illustrating the relationship between the extrahepatic bile duct, hepatic artery proper, and portal vein. The figure also demonstrates the boundaries of the hepatocystic triangle of Calot and vascular supply to common bile duct at the 3 and 9 o’clock position. CBD: Common bile duct
Figure 2
Figure 2
Transductal bile duct stone removal using the chopstick technique. Two atraumatic instruments are placed on the right-posterior and the left-anterior side of the common bile duct.
Figure 3
Figure 3
Confirmation of complete ductal clearance by choledochoscopy. The choledochoscope should pass proximally to visualize the left and right intrahepatic ducts, as well as distally to the duodenum, to ensure complete ductal examination. Additionally, irrigation with normal saline solution via the choledochoscope proves beneficial for flushing out small stones and sludge.
Figure 4
Figure 4
Ductal closure following complete transductal common bile duct stone removal. Typically, intracorporeal suturing with interrupted 4-0 or 5-0 absorbable sutures is utilized. Based on current evidence, the closure-over-stent technique, which involves inserting a 7-10 French biliary stent followed by primary suture, is recommended.
See this image and copyright information in PMC

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