Surgical common bile duct exploration

INTRODUCTION — Common bile duct (CBD) stones are identified in 10 to 15 percent of patients undergoing surgery for symptomatic cholelithiasis [1]. CBD stones require extraction for management of symptoms and to prevent complications such as acute suppurative cholangitis, obstructive jaundice, hepatic abscess, and acute pancreatitis.

In the past, CBD stones were diagnosed with intraoperative cholangiography and treated with open CBD exploration. Advances in preoperative imaging technology such as magnetic resonance cholangiopancreatography (MRCP) (image 1 and image 2) and endoscopic ultrasound (image 3), as well as the development of endoscopic retrograde cholangiopancreatography (ERCP) and minimally invasive surgical techniques, have allowed for less invasive and more accurate methods of identifying and treating CBD stones.

This topic will review laparoscopic and open CBD exploration. The diagnosis and the endoscopic treatment of choledocholithiasis (ie, ERCP) are discussed elsewhere. (See "Choledocholithiasis: Clinical manifestations, diagnosis, and management" and "Endoscopic management of bile duct stones".)

IDENTIFICATION OF CBD STONES — Choledocholithiasis is present in 10 to 15 percent of patients undergoing cholecystectomy for uncomplicated, symptomatic cholelithiasis [2]. The risk of harboring common bile duct (CBD) stones can be estimated preoperatively based on pertinent findings on the history, physical examination, laboratory testing, and/or transabdominal ultrasound [3]. This is discussed in detail in another topic. (See "Choledocholithiasis: Clinical manifestations, diagnosis, and management", section on 'Whom to suspect'.)

High- and intermediate-risk patients should undergo further imaging of the CBD, while low-risk patients may proceed to cholecystectomy directly (algorithm 1):

●High-risk patients have an estimated probability of having a CBD stone of >50 percent and should undergo endoscopic retrograde cholangiopancreatography (ERCP) to both diagnose and remove any CBD stones prior to cholecystectomy.

While preoperative ERCP is clearly indicated for ascending cholangitis or jaundice [4], some providers advocate confirming the presence of CBD stones prior to performing ERCP for stone removal in order to minimize the potential complications associated with ERCP. Imaging modalities that can be used include magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS) for CBD stones and abdominal computed tomography (CT) for pancreatobiliary malignancy [5].

●Intermediate-risk patients have an estimated 10 to 50 percent probability of having a CBD stone and can be managed with either preoperative MRCP or endoscopic ultrasound. Alternatively, such patients may also proceed directly to laparoscopic cholecystectomy with intraoperative cholangiography. CBD stones identified on intraoperative cholangiogram can be removed by laparoscopic CBD exploration (in centers with the requisite expertise) or by intraoperative or postoperative ERCP.

●Low-risk patients have an estimated <10 percent probability of having a CBD stone and do not require further imaging of the CBD prior to cholecystectomy.

Intraoperative cholangiography — During cholecystectomy, intraoperative cholangiography may be performed to confirm the diagnosis of choledocholithiasis and/or outline the biliary anatomy.

Some surgeons perform routine intraoperative cholangiography in all patients undergoing cholecystectomy. Proponents of routine cholangiography describe the added benefit of practice and training to improve outcomes during more challenging cases.

We selectively perform intraoperative cholangiography based upon findings such as elevated liver function tests, a dilated common bile duct (>6 mm), or a history of pancreatitis.

Laparoscopic intraoperative cholangiography — For laparoscopic intraoperative cholangiography, the cholangiocatheter is placed after careful dissection achieves the critical view of safety (figure 1). (See "Laparoscopic cholecystectomy", section on 'Critical view of safety'.)

A clip is applied proximally across the cystic duct once it is well visualized. A transverse ductotomy is created, taking care not to completely divide the posterior wall of the cystic duct. The contents of the cystic duct are milked toward the ductotomy in order to prevent passage of stones or debris into the common duct. A cholangiogram catheter (4 to 5 French) with a metal reinforced tip is inserted through a 14 gauge angiocatheter that has been placed percutaneously in the right upper quadrant of the abdomen.

The cholangiocatheter is manipulated into the cystic duct with laparoscopic instruments. Commercially available cholangiocatheters use either jaws of a grasping instrument or an inflatable balloon to secure the catheter and occlude the ductotomy opening after catheter placement. Alternatively, a clip or a cholangiogram clamp can be loosely applied around the cystic duct with the catheter inside. Placement of a hydrophilic guidewire through the cholangiocatheter facilitates placement of instruments for CBD stone extraction and dilatation of the cystic duct with balloon catheters or mechanical dilators if necessary [6]. (See 'Dilation of the cystic duct' below.)

The position and seal of the cholangiocatheter should be first tested with injection of saline. The saline and water-soluble contrast filling the tubing must be free of air bubbles as air bubbles can create filling defects that mimic the appearance of stones.

A 1:1 dilution of water-soluble contrast and water is then injected under continuous fluoroscopic visualization. The images should be evaluated for the length of the cystic duct and its junction with the CBD, the size of the CBD, free flow of contrast into the duodenum, the intra- and extrahepatic biliary anatomy, and the presence of filling defects. If the contrast does not flow freely into the duodenum, administration of sublingual nitroglycerin or intravenous glucagon is sometimes helpful for relaxing the sphincter of Oddi.

Proximal bile ducts must also be visualized, and techniques to facilitate this include administration of intravenous morphine (to contract the sphincter of Oddi), positioning the patient in steep Trendelenburg, and applying pressure to the distal bile duct with a laparoscopic instrument. Misplacement of the cholangiocatheter into the CBD may also prevent the visualization of the proximal biliary tree. Findings on cholangiography that are suggestive of CBD stones include a dilated bile duct, filling defects (image 4), or failure of contrast to flow into the duodenum [7].

The right-sided hepatic duct is particularly important to identify during intraoperative cholangiography because the right posterior section duct (segment 6 and 7) is vulnerable to injury as it inserts into the central biliary tree at variable locations, including below the bifurcation, cystic duct, gallbladder, or main left duct [8]. Failure to visualize the right-sided ductal structures should raise concern for aberrant anatomy or iatrogenic injury.

MANAGEMENT OF CBD STONES — Once identified, common bile duct (CBD) stones should be removed to prevent complications such as jaundice, cholangitis, or pancreatitis. Laparoscopic CBD exploration, open CBD exploration, and endoscopic retrograde cholangiopancreatography (ERCP) with stone removal are all options for the removal of CBD stones.

●CBD stones identified by preoperative ERCP are removed by ERCP.

●When ERCP is not available, is not feasible (eg, due to surgically altered anatomy such as Roux-en-Y gastric bypass), or fails, surgical CBD exploration, either laparoscopic or open, may be the only option. In some patients, enteric access via laparoscopic-assisted ERCP may be performed by placing trocars directly into the stomach remnant for endoscope insertion and CBD cannulation. (See "Endoscopic retrograde cholangiopancreatography (ERCP) after Billroth II reconstruction".)

●When CBD stones are identified by preoperative magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound, or by intraoperative cholangiography, and both surgical CBD exploration and ERCP are feasible, the choice is guided by patient-specific considerations (eg, biliary tree anatomy), training and experience of the surgeon and endoscopist, and available local resources and equipment [8,9].

Laparoscopic cholecystectomy with concomitant CBD exploration has the advantage of being a single-stage procedure that both removes the gallbladder and clears the CBD. The disadvantages are that it requires greater technical expertise and equipment and takes a longer operative time than straightforward laparoscopic cholecystectomy. ERCP has the advantage of being able to clear the CBD without surgery. The main disadvantage is that it is usually performed as a second procedure before or after cholecystectomy, and less frequently at the same time as the gallbladder surgery for logistical reasons. Another theoretical downside to postoperative ERCP is the need for a reoperation for duct clearance if it fails, although this is likely rare in centers with significant ERCP experience. Open CBD exploration remains an option but is usually not performed when cholecystectomy can be completed laparoscopically; postoperative ERCP is the preferred option in this situation [10].

Outcomes for laparoscopic versus endoscopic treatment have been compared in randomized trials and observational studies. A 2013 Cochrane review found no significant difference in the mortality and overall morbidity rates between laparoscopic cholecystectomy performed with either laparoscopic CBD exploration or ERCP [11]. In other studies, surgical CBD exploration had higher [12,13], lower [14], or equal success rates [15-17] compared with ERCP, although the hospital length of stay is generally shorter with the single-stage laparoscopic cholecystectomy/CBD exploration approach [12].

In the United States at least, the use of ERCP is rising and the use of surgical CBD exploration is declining. In a study of over 40,000 patients with choledocholithiasis who underwent laparoscopic cholecystectomy in 2002, 93 percent underwent ERCP and 7 percent underwent laparoscopic CBD exploration [18]. A similar study of over 37,000 patients between 1998 and 2013 found that 97 percent underwent ERCP and 3 percent underwent laparoscopic CBD exploration [19]. The overall use of open CBD exploration decreased from 30.6 percent in 1998 to 5.5 percent in 2013 and the use of laparoscopic CBD exploration from 9.2 to 3 percent in the same time period.

The techniques of surgical CBD exploration are discussed in the following sections. The techniques of ERCP are discussed in other topics. (See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in adults" and "Endoscopic management of bile duct stones".)

PREOPERATIVE PREPARATION — Informed consent should include a discussion of the risks, benefits, and alternatives of common bile duct (CBD) exploration. The patient should be counseled regarding the possibility of bile leak, abscess, cholangitis, pancreatitis, biliary stricture, and retained CBD stones. (See 'Complications' below.)

Prophylactic antibiotics — Patients with suspected and confirmed CBD stones should be given perioperative antibiotics. A first- or second-generation cephalosporin is recommended within one hour prior to the incision (table 1) [20]. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Antimicrobial prophylaxis'.)

Equipment — Appropriate equipment should be readily available, including 3 to 5 French (F) biliary Fogarty catheters, wire baskets, 0.0035 inch guidewire, balloon (8 mm outer diameter) and/or mechanical (7 to 12 F) dilators, a 3 to 5 mm choledochoscope with a 1.1 mm or larger working channel, loop ligatures, and T-tubes.

Additional choledochoscopic equipment includes a separate light source, an adaptor to allow simultaneous irrigation via the biopsy channel, a second camera and monitor, or picture-in-picture display with video switcher.

Fluoroscopy equipment and support should be available for all patients undergoing cholecystectomy; it may be required for both intraoperative cholangiography and CBD exploration.

LAPAROSCOPIC CBD EXPLORATION — Laparoscopic common bile duct exploration (LCBDE) can be performed via the cystic duct (transcystic approach) or an incision in the CBD (choledochotomy approach). In general, small distal stones are best suited for transcystic removal, while large or proximal stones may require a choledochotomy approach.

Laparoscopic transcystic exploration — In most candidates for surgical CBD exploration, CBD stones are identified by intraoperative transcystic cholangiography. Since access to the cystic duct has already been obtained, laparoscopic transcystic exploration of the CBD is the logical technique to initiate CBD exploration in most patients [21-24].

For patients with stones smaller than 10 mm and a small bile duct, laparoscopic transcystic exploration of the CBD is faster, safer, and less invasive compared with laparoscopic choledochotomy. In an observational series of 113 patients undergoing CBD exploration, operative time (97 versus 75 minutes) and length of hospital stay (six versus two days) were significantly longer for choledochotomy than for transcystic exploration, although stone clearance and morbidity rates were similar [24]. The morbidity of transcystic CBD exploration is equivalent to that of a standard laparoscopic cholecystectomy alone [22,23].

Conditions ideal for transcystic laparoscopic CBD exploration include [8]:

●CBD diameter <7 mm

●Stone location distal to the cystic duct/CBD junction

●Cystic duct diameter >4 mm

●Fewer than six to eight stones within the CBD

●Stones smaller than 10 mm

●Lateral entrance of cystic duct to CBD

For laparoscopic transcystic exploration, the gallbladder is left in situ and the dome of the gallbladder is grasped and retracted cephalad to facilitate visualization and manipulation (figure 2). After intraoperative cholangiography is performed (see 'Laparoscopic intraoperative cholangiography' above), potential maneuvers and the general sequence in which they should be attempted include [8]:

Flushing of the bile duct — Flushing of the distal CBD with warm saline should be the initial maneuver performed for clearance of nonobstructing CBD stones and can be facilitated by intravenous administration of 1 to 2 mg of glucagon to relax the sphincter of Oddi. Small stones <4 mm in diameter are likely to pass into the duodenum with flushing. Flushing of the proximal duct is avoided because small stones could be pushed into hepatic ducts and become irretrievable. A laparoscopic grasper can be left secured to the dome of the gallbladder in order to facilitate retraction and visualization throughout the procedure.

Dilation of the cystic duct — If CBD stones do not pass by flushing the distal CBD, they will require extraction. To facilitate the passage of instruments and stones, the cystic duct can be dilated to 4 to 6 mm with an over-the-wire balloon or mechanical dilator, although many cystic ducts are already dilated due to the passage of stones.

Transcystic stone retrieval — Stone retrieval can be accomplished with either a biliary balloon (Fogarty) catheter or a wire basket guided fluoroscopically, or by transcystic choledochoscopy-guided basket retrieval. The choice depends on available expertise and equipment.

Surgeons who routinely perform laparoscopic transcystic CBD exploration prefer the choledochoscopy method because the stones can be retrieved under direct vision [25]. In an observational series of 113 patients undergoing CBD exploration, operative time (107 versus 75 minutes) was significantly longer for fluoroscopically guided stone retrieval than with choledochoscopy, although stone clearance and morbidity rates were similar [24].

Biliary balloon catheter extraction — A 3 to 5 F biliary Fogarty catheter is advanced transcystically into the duodenum under fluoroscopic guidance. Duodenal placement can be confirmed by fluoroscopy or by resistance upon withdrawal of the catheter following balloon inflation, indicating that the balloon is beyond the ampulla of Vater. The balloon should be deflated and withdrawn slightly. The balloon can then be gently inflated and withdrawn carefully until stones and debris exit from the cystic ductotomy for retrieval with forceps. Because the stones are not grasped directly with this procedure, there is a risk of further impacting a stone into the duodenum or displacing a stone into the common hepatic duct. Of note, a biliary Fogarty balloon may not be long enough for some cases, for which a vascular embolectomy catheter can be used.

Fluoroscopy-guided wire basket retrieval — Fluoroscopy-guided wire basket retrieval of stones can be performed if fluoroscopy and specialized equipment are available [26]. The use of spiral wire baskets with flexible leaders will help avoid CBD injury. The basket is placed over the wire and guided into the lower common duct or duodenum under fluoroscopy, then opened and pulled back until the stone is captured. Rates of successful stone retrieval with this technique are reported as 95 percent in case series [27].

Transcystic choledochoscopy-guided retrieval — The choledochoscope is inserted into the abdomen through a dedicated 5 mm port placed midway between the subxiphoid and right midclavicular ports to be in line with the bile duct.

The choledochoscope can be manipulated into the cystic duct with atraumatic instruments. Alternatively, insertion of the choledochoscope can be guided by a 0.035 inch guidewire threaded into its operating channel using the Seldinger technique: following intraoperative cholangiogram, the guidewire can be placed through a 5 French open-tip cholangiogram catheter and advanced well into the duodenum under fluoroscopy to prevent retrograde migration. Following cystic duct dilation over the guidewire, the choledochoscope can then be inserted over the same wire.

Either way, as the choledochoscope is advanced into the CBD, continuous pressurized saline irrigation improves visualization. Additional video monitors or screen-in-screen technology are required for monitoring.

When a stone is seen through the choledochoscope, wire basket retrieval can be performed under direct vision. Adaptors are required for insertion of wire retrieval baskets via the operating channel of the choledochoscope. Distal CBD stones can also be pushed into the duodenum with the choledochoscope. Proximal stones may require treatment with other techniques; choledochoscopic visualization of the proximal biliary tree is technically challenging via the transcystic approach due to the angle at which the cystic duct inserts into the CBD. (See 'Laparoscopic choledochotomy' below.)

Completion cholangiography — Following laparoscopic transcystic exploration, duct clearance should be confirmed with a completion cholangiogram (image 5). The cystic duct stump is then secured with a clip or a loop ligature. Loop ligatures minimize the possibility of postoperative bile leak for patients with cystic duct dilation, trauma, or inflammation. The cholecystectomy is completed, and the placement of a closed suction drain in the hepatic fossa may be considered to identify and control any bile leakage but is not mandatory after a routine transcystic laparoscopic CBD exploration. (See "Laparoscopic cholecystectomy", section on 'Standard procedure'.)

Laparoscopic choledochotomy — Laparoscopic choledochotomy (LCD) is more technically demanding than laparoscopic transcystic CBD exploration. Therefore, LCD is typically only attempted following failed laparoscopic transcystic exploration or for patients who are not candidates for the transcystic approach.

Conditions that favor LCD include [28]:

●Failed laparoscopic transcystic exploration or preoperative endoscopic stone extraction.

●Narrow/tortuous cystic duct.

●Dilated CBD (>7 mm). Some authors further advocate that LCD should only be attempted if the CBD is >8 mm, or even >10 mm in diameter to reduce the risk of postoperative stricturing [8].

●Large stones (>10 mm).

●Multiple stones.

●Stone location proximal to the cystic duct/CBD junction.

●Distal or posterior cystic duct entrance to CBD.

As is the case for laparoscopic transcystic exploration, the gallbladder is left in situ and the dome of the gallbladder is grasped and retracted cephalad to facilitate visualization and manipulation. A 30 degree laparoscope should be used to assist with visualization of the supraduodenal CBD.

Laparoscopic choledochotomy creation — The cystic duct should be dissected to the level of the CBD, and the tissue overlying the anterior CBD should be cleared for 2 cm above the duodenum. Care should be taken to avoid excessive dissection because this may compromise the blood supply to the CBD, which is lateral at 3' and 9 o'clock. A longitudinal incision of approximately 1 cm is created with laparoscopic scissors or a laparoscopic 11 blade scalpel; stay sutures will help to facilitate manipulation and maintain a seal when saline is infused during choledochoscopy.

Laparoscopic stone retrieval — Various techniques such as saline flushing, fluoroscopy-guided balloon or wire basket retrieval, and choledochoscopy can be utilized for extraction of CBD stones. The same techniques have been described above and will not be repeated here. (See 'Transcystic stone retrieval' above.)

Unlike the transcystic approach, however, the choledochotomy allows the choledochoscope to be inserted retrograde into the common hepatic duct and right/left hepatic ducts, as well as anterograde into the common bile duct. A wire basket can be deployed via the operating channel of the choledochoscope to retrieve any stone in the entire biliary tree.

Laparoscopic choledochotomy closure — Primary closure of the choledochotomy can be accomplished with interrupted 4-0 or 5-0 monofilament absorbable sutures. Absorbable sutures should be used in the bile duct since permanent suture is lithogenic [1]. Compared with T-tube closure, primary closure is associated with decreased operating time, decreased postoperative and biliary complications, shorter time until return to work, and decreased hospital costs [29-34]. Based on currently available evidence, there is no justification for the routine use of T-tube drainage after laparoscopic CBD exploration in patients with CBD stones [34].

In cases where residual stones are suspected and ERCP expertise is not available, a T-tube (12 to 16 F) can be placed through the choledochotomy (figure 3) and secured in place using fine monofilament absorbable sutures. T-tube drainage has traditionally provided a method for postoperative biliary decompression and access to the bile duct for cholangiography and possible stone extraction; however, T-tubes can be associated with complications such as bile leak, infection, tube dislodgement, or bile duct obstruction [21]. In addition, the T-tube can act as a foreign body around which bile pigments and bile salts may precipitate, potentially leading to stone recurrence. If a T-tube is placed, cholangiography should always be performed prior to its removal in order to confirm duct clearance and to rule out bile leaks. (See 'T-tube management' below.)

OPEN CBD EXPLORATION — Open common bile duct (CBD) exploration remains an important technique and should be part of every gastrointestinal surgeon's armamentarium for treating hepatobiliary diseases. Surgeons performing laparoscopic cholecystectomy should be prepared to convert to open CBD exploration if necessary. However, conversion to open surgery solely to perform CBD exploration when cholecystectomy can be performed laparoscopically is not indicated, as postoperative endoscopic retrograde cholangiopancreatography (ERCP) is probably a better option with lower morbidity in this situation [10].

Open CBD exploration may be performed in the following situations:

●Patients with CBD stones who are undergoing open cholecystectomy

●Patients who have failed or suffered complications from laparoscopic CBD exploration

●Settings where laparoscopic and endoscopic (ERCP) equipment, experience, and/or resources are not available

Open incision — As for open cholecystectomy, the abdomen is most commonly opened through a right upper quadrant subcostal incision, although a midline approach is acceptable as well. The liver should be retracted superiorly, the duodenum retracted inferiorly, and the stomach retracted to the left. A generous Kocher maneuver should be performed, which will allow for manual palpation and manipulation of the distal CBD. (See "Open cholecystectomy", section on 'Incision'.)

Open choledochotomy creation — The proximal cystic duct should be ligated to prevent gallstones from migrating from the gallbladder into the cystic duct and CBD. Dissection is carried onto the anterolateral CBD, stay sutures (fine monofilament, absorbable suture) are placed just above the level of the duodenum, and the duct is opened longitudinally. The choledochotomy is then extended with Potts scissors to a length of approximately 1.5 cm.

Open stone retrieval — Stones can initially be extracted using manual manipulation of the CBD. If this is not successful, balloon extraction can be performed with biliary Fogarty catheters, clearing the proximal duct before the distal duct. These catheters are preferred to metal forceps because they are less traumatic [35]. Saline flushing can facilitate the removal of fragmented debris. Choledochoscopy with wire basket retrieval can be employed in the unlikely event that balloon extraction is unsuccessful. (See 'Transcystic stone retrieval' above.)

Open choledochotomy closure — As is the case for laparoscopic CBD exploration, primary closure of the choledochotomy can be a safe alternative to T-tube placement in patients undergoing open CBD exploration [30,36-38]. A 2013 Cochrane review concluded that T-tube drainage was associated with significantly longer operating time and hospital stay compared with primary closure without any apparent benefit in clinically important outcomes. Based on the currently available evidence, there is no justification for the routine use of T-tube drainage after open CBD exploration in patients with CBD stones [38].

T-tube placement — However, many surgeons still prefer to place a T-tube following open CBD exploration when there is concern for potential stricturing or increased pressure within the duct due to inflammation or edema of the papilla, or retained stones. When endoscopic access to the duct has failed or is not available or possible, placement of a T-tube will allow access to the duct for any retained stones.

The largest T-tube that will easily fit into the CBD is selected. The ends are usually trimmed obliquely to facilitate placement, and the posterior wall of the T-tube is opened with scissors to facilitate collapse and folding of the catheter at the time of removal (figure 3). The choledochotomy is closed over the T-tube with fine absorbable monofilament sutures. The T-tube is generally brought out of the abdomen through a separate stab incision and secured firmly to the skin. (See 'T-tube management' below.)

POSTOPERATIVE CARE — Routine postoperative care is similar to that of laparoscopic or open cholecystectomy. Liver function tests (LFTs) should be measured if patients develop complications or if there is a concern for retained stones, but LFTs may take over one week to normalize after surgery [39]. The management of tubes and drains is as follows. (See "Laparoscopic cholecystectomy", section on 'Routine postoperative care' and "Open cholecystectomy", section on 'Routine care'.)

T-tube management — If a T-tube has been placed, a T-tube cholangiogram is performed 24 to 48 hours postoperatively (image 6). If normal, the T-tube is flushed with 10 mL of sterile normal saline one to two times a day and otherwise clamped for 10 to 14 days prior to removal [8]. If the initial T-tube cholangiogram shows biliary obstruction or retained stones, the T-tube is left open for one to two weeks. If a repeat T-tube cholangiogram shows persistent stone or biliary obstruction, endoscopic retrograde cholangiopancreatography (ERCP) or interventional radiologic procedure via the T-tube is required to clear the duct. A normal T-tube cholangiogram and LFTs should be ascertained prior to T-tube removal.

Drain placement — Following laparoscopic or open CBD exploration where a choledochotomy has been made, we place a closed suction type drain (eg, Jackson-Pratt) to gravity drainage. Bulb suction is not applied, to avoid high negative pressures to the operative field.

In patients with a T-tube, the drain should be kept until a T-tube cholangiogram shows no biliary leak or stenosis. In patients without a T-tube, the drain may be removed after LFTs normalize without bilious drain output; alternatively, a HIDA scan can also be obtained to access the biliary anatomy prior to drain removal.

COMPLICATIONS — According to data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, laparoscopic common bile duct (CBD) exploration has significantly lower mortality (0.25 versus 5.5 percent), surgical site infection rate (1.2 versus 10 percent), and overall morbidity rate (3.7 versus 22 percent) compared with open CBD exploration [40]. However, the increased morbidity and mortality associated with open exploration may be a reflection of underlying comorbidities or more complicated disease requiring an open approach [41].

Patients who present with fever, leukocytosis, persistent pain, bile leakage around the T-tube or drain, jaundice, or rigors after CBD exploration should be evaluated for fluid collections or CBD blockage with ultrasound and/or computed tomography (CT) scanning. The clinical and radiologic evaluation of a bile leak or obstruction is discussed in detail elsewhere. (See "Complications of laparoscopic cholecystectomy", section on 'Imaging'.)

Specific complications of open and laparoscopic CBD exploration include:

Bile duct leak — Bile may leak from the cystic duct orifice, cystic duct-CBD junction, or the CBD itself. It occurs in 2 to 16 percent of cases [42-44]. Bile duct leak usually resolves with percutaneous drainage with or without endoscopic retrograde cholangiopancreatography (ERCP) and transampullary stent placement. There is no evidence that a T-tube prevents bile duct leak. (See 'Laparoscopic choledochotomy closure' above and 'Open choledochotomy closure' above.)

Persistent stones — Stones persist in the CBD in 0 to 5 percent of patients after surgical CBD exploration [42,44,45].

Retained stones — Laparoscopic CBD exploration results in stone clearance in over 90 percent of patients [7,46,47]. Options for management of persistent CBD stones after laparoscopic transcystic exploration include laparoscopic or open choledochotomy and CBD exploration, postoperative ERCP and stone extraction, percutaneous stone removal, or observation (in the case of stones <2 mm) (image 7 and image 8). The choice of procedure should be guided by patient-specific considerations (eg, biliary tree and gastrointestinal tract anatomy), the training and experience of the surgeon, and available endoscopic expertise.

Laparoscopic-endoscopic rendezvous technique — When CBD clearance has not been achieved at the end of the surgical procedure, some surgeons place transcystic biliary drainage catheters to prevent complete biliary obstruction and allow for future biliary access by facilitating ERCP cannulation [48,49].

These wire-guided catheters can be placed laparoscopically through a transcystic or transcholedochal approach under fluoroscopy guidance and are easier to place and manage than T-tubes. The catheter can be secured with absorbable sutures to the cystic duct and externally at the skin level. An alternative to external catheters is a laparoscopic endobiliary stent [50].

Transcystic biliary drainage catheters or endobiliary stents allow patients with retained CBD stones to be discharged home and return for elective ERCP when immediate postoperative ERCP is not available. A Cochrane review of five trials comparing the rendezvous technique with preoperative ERCP associated the former with longer operative time but shorter hospital stay but did not deliver a definitive endorsement due to low-quality evidence [51].

Impacted stones — Rarely, severely impacted stones are encountered (image 9). Impacted stones are difficult to remove with Fogarty balloon catheters or wire baskets. Surgeons who have experience with laser or electrohydraulic lithotripsy or duodenotomy with sphincterotomy may be able to complete stone extraction with one of these techniques [52]. Alternatively, impacted stones may be removed by postoperative ERCP. (See "Laser lithotripsy for the treatment of bile duct stones" and "Endoscopic management of bile duct stones" and "Electrohydraulic lithotripsy in the treatment of bile and pancreatic duct stones".)

A rare but unique complication of wire basket stone extraction is an impacted stone in the wire basket, which occurs when the stone is too large to remove through the cystic duct [53]. An impacted stone in the wire basket can be removed by extending the cystic ductotomy to the confluence with the CBD or by making a separate incision on the CBD, cutting the wire, and retrieving the basket with the stone.

Bile duct stricture — Strictures of the bile duct are a long-term complication of CBD exploration that occurs in 0 to 0.8 percent of cases [54,55]. The risk is lower after transcystic exploration compared with choledochotomy. To minimize the risk, laparoscopic choledochotomy should be avoided when the CBD is <7 mm in diameter [8]. (See 'Laparoscopic choledochotomy' above.)

Pancreatitis — Pancreatis occurs in 0 to 3 percent of patients following CBD exploration due to reflux of contrast into the pancreatic duct or ampullary obstruction by stones, edema, or blood clots [15,45]. In the latter case, ERCP may be required to relieve the obstruction.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gallbladder surgery".)

SUMMARY AND RECOMMENDATIONS

●Choledocholithiasis – Common bile duct (CBD) stones are identified in 10 to 15 percent of patients undergoing surgery for symptomatic cholelithiasis. CBD stones should be removed surgically or endoscopically to prevent further complications such as acute suppurative cholangitis, obstructive jaundice, hepatic abscess, and acute pancreatitis. (See 'Introduction' above.)

●Diagnosis – Prior to gallbladder surgery, patients should be risk-stratified in terms of their probability of having choledocholithiasis. High-risk patients with jaundice or cholangitis should undergo preoperative endoscopic retrograde cholangiopancreatography (ERCP); intermediate-risk patients may undergo preoperative magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound or intraoperative cholangiography; low-risk patients do not require further imaging of the CBD (algorithm 1). (See 'Identification of CBD stones' above and "Choledocholithiasis: Clinical manifestations, diagnosis, and management", section on 'Whom to suspect'.)

●Management – CBD stones identified by preoperative ERCP are removed by ERCP. When ERCP is not available, is not feasible (eg, due to surgically altered anatomy such as Roux-en-Y gastric bypass), or fails, surgical CBD exploration, either laparoscopic or open, becomes the only option. When both surgical CBD exploration and ERCP are feasible, the choice is guided by patient-specific considerations (eg, biliary tree anatomy), training and experience of the surgeon and endoscopist, and available local resources and equipment. Laparoscopic and endoscopic treatment of CBD stones have similar outcomes in randomized trials and observational studies. (See 'Management of CBD stones' above.)

•Laparoscopic CBD exploration – Laparoscopic CBD exploration can be performed via the cystic duct (transcystic approach) or an incision in the CBD (choledochotomy approach). Choledochotomy is typically only performed when the duct cannot be cleared using a transcystic approach. Laparoscopic choledochotomy should be avoided if the CBD is <7 mm in diameter to reduce the risk of postoperative stricturing. (See 'Laparoscopic CBD exploration' above.)

•Open CBD exploration – Surgeons performing laparoscopic cholecystectomy should be prepared to convert to open CBD exploration if necessary. However, one does not typically convert to open surgery solely to perform CBD exploration when cholecystectomy can be otherwise be performed laparoscopically. Postoperative ERCP is less morbid in this situation. (See 'Open CBD exploration' above.)

•Stone retrieval – CBD stones can be retrieved using methods such as saline flushing, biliary Fogarty balloon catheter, and wire basket. Wire basket can be deployed under fluoroscopic or choledochoscopic guidance. Each method can be applied via laparoscopic transcystic, laparoscopic transcholedochal, and open approaches. (See 'Flushing of the bile duct' above and 'Transcystic stone retrieval' above and 'Laparoscopic stone retrieval' above and 'Open stone retrieval' above.)

•Choledochotomy closure – We suggest primary closure of both laparoscopic and open choledochotomy rather than T-tube closure (Grade 2C). T-tube closure has been associated with higher complication rates without any benefits. T-tubes may be used when there is concern for retained stones and when endoscopic expertise is not available. (See 'Laparoscopic choledochotomy closure' above and 'Open choledochotomy closure' above.)

●Outcomes – Laparoscopic CBD exploration has been associated with lower mortality and morbidity than open CBD exploration. Specific complications of both include bile leak (2 to 16 percent), retained stones (0 to 5 percent), bile duct stricture (0 to 1 percent), and pancreatitis (0 to 3 percent).

ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges W Scott Melvin, MD, and Peter Muscarella, MD, who contributed to an earlier version of this topic review.