Open or Laparoscopic Common Bile Duct Exploration (Choledocholithotomy):

Laparoscopic Exploration and Cholangiography

Surgeons are now increasingly using laparoscopy with cholangiography instead of ERCP when common duct stones are suspected. Laparoscopy with cholangiography should only be done in centers with expertise in this procedure. Potential indications include.

• An alternative to ERCP before gallbladder surgeries, when there is high suspicion of common bile duct stones.
• During gallbladder surgeries when common duct stones are detected or highly suspected.

The procedure usually involves the following steps:

• The initial approach is the same as with laparoscopic cholecystectomy. Small incisions, one or two 10 - 12 mm (around half an inch) and three 5 mm (about a fifth of an inch), are made in the abdomen.
• A tiny opening is made in the cystic duct that connects the gallbladder to the bile duct, and a thin tube is introduced to perform a cholangiography. Cholangiography also reduces the risk for injury in the common duct.
• If stones are identified, the surgeon inserts a tube with an inflatable balloon to widen the duct.
• Stones are usually retrieved or withdrawn from the duct either with the use of a balloon or with a tiny basket.
• If laparoscopy is unsuccessful, ERCP or open surgery is performed.

Experts are debating whether this procedure is better than ERCP. Many surgeons believe that laparoscopy is becoming safe and effective, and should be the first choice of treatment. Still, laparoscopy for common duct stones should be performed only by surgeons experienced in this new and demanding technique.

Open Common Bile Duct Exploration (Choledocholithotomy)

Choledocholithotomy, or common bile duct exploration, is used:

• To remove large stones
• When the duct anatomy is complex
• During or after some gallbladder operations when stones are detected. If the procedure is laparoscopy, surgeon may convert to open procedure, though this happens less often now.
• When ERCP or laparoscopic procedures are not available.

In this procedure, the doctor carries out open abdominal surgery and extracts gallstones through an incision in the common bile duct. Routinely, a so-called "T-tube" is temporarily left in the common bile duct after surgery and the doctor x-rays the bile duct through the tube 7 - 10 days after surgery, to determine if any stones remain in the duct.