Biliary Tree Stones

Choledocholithiasis is present in about 4–10 % of patients with gallstones. Before the development of laparoscopic procedures, open cholecystectomy, choledochotomy, stone extraction, and T-tube placement were the gold standard treatment for gallstones and common bile duct stones; intraoperative cholangiography or cholangioscopy could be also performed in patients suspected of having common bile duct stones (CBDS). In the last decades several different treatments of CBDS have been developed, such as laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy (ES) or laparoscopic common bile duct exploration with stone extraction through a trans-cystic or a trans-choledochotomical way. However, during the early laparoscopic experience, preoperative ERCP and ES have remained the preferred treatment for suspected CBDS, whereas postoperative ERCP has considered the favorite treatment for stones occasionally discovered during LC or after surgery. Indeed, laparoscopic trans-cystic duct clearance can be achieved in only 25–75 % of patients, and choledochotomy is supposed to be associated with longer operatory time and postoperative biliary complications especially in case of local inflammation and small CBD. Furthermore, laparoscopic management of CBDS requires the availability of local resources and skilled surgeons with experience in advanced minimally invasive procedure. In fact the complications related with ERCP may be life threatening. Thus, the clinicians have to face several options for the treatment of patients suffering from suspected CBDS; each of them shares their own pros and contras.