Laparoscopic Common Bile Duct Exploration Four-Task Training Model: Construct Validity

To evaluate the effectiveness of laparoscopic common bile duct exploration in unselected patients. Consecutive sample. Tertiary care general hospital. Three hundred and two patients with symptomatic cholelithiasis presenting to a single surgeon during a 5-year period. Laparoscopic cholecystectomy, cholangiography, and common bile duct exploration. Successful laparoscopic cholecystectomy and common bile duct exploration. Three hundred and two consecutive patients underwent cholecystectomy for symptomatic cholelithiasis; 280 of the procedures were successfully completed laparoscopically. Cholangiography was attempted in 269 patients, was successful in 239, and revealed evidence of choledocholithiasis in 25. Preoperative ultrasonography and liver function tests predicted the presence of common bile duct stones in 24% and 32% of patients, respectively. Seven of the patients with choledocholithiasis presented with biliary colic, 7 with biliary colic and jaundice, 8 with acute cholecystitis (3 with gallbladder perforation), 1 with acute cholecystitis and jaundice, and 2 with gallstone pancreatitis. Four of 5 patients underwent successful transcystic exploration with a biliary Fogarty catheter, 12 of 16 patients underwent successful transcystic choledochoscopy and stone basket extraction, and all 4 attempts at choledochotomy and choledochoscopic stone basket extraction were successful, for a total success rate of 80% with laparoscopic common bile duct exploration. One of the failures was converted to an open procedure, and 4 of the failures had successful postoperative endoscopic retrograde cholangiopancreatography and extraction of stones. Laparoscopic cholecystectomy and common bile duct exploration is a highly successful procedure for the management of common duct stones in an unselected group of patients. Choledochotomy with choledochoscopy is the preferred method of common bile duct exploration.

BackgroundT-tube drainage following laparoscopic common bile duct (CBD) exploration may lead to T-tube displacement and water–electrolyte disorders, affecting patients’ quality of life. In particular, biliary peritonitis may develop in a small number of patients after T-tube removal, requiring reoperation. This prospective cohort study was performed to investigate the safety and feasibility of primary closure following laparoscopic CBD exploration for the treatment of choledocholithiasis.MethodsPatients who were treated for choledocholithiasis by laparoscopic CBD exploration with primary closure from January 2019 to March 2022 comprised the PC group (n = 145). Patients who were treated for choledocholithiasis by laparoscopic CBD exploration with T-tube drainage during this period comprised the TD group (n = 153). Perioperative and follow-up outcomes were collected and statistically analyzed.ResultsThe TD and PC groups showed significant differences in the operation time (124.6 ± 40.8 vs. 106 ± 36.4 min, P = 0.000) and postoperative hospital stay (7.1 ± 2.6 vs. 5.9 ± 2.0 days, P = 0.000). No significant difference was observed in terms of blood loss, the ratio of conversion to laparotomy, and postoperative parameters. Preoperative albumin and total bilirubin levels were the risk factors of bile leakage after surgery. No patients developed CBD stricture or carcinogenesis, The rates of residual and recurrent stones in the TD and PC groups were 1.97% vs. 1.40% and 1.31% vs. 1.40%, respectively, with no significant difference (P = 1.000 for both).ConclusionsPrimary closure following laparoscopic CBD exploration is safe and feasible for selected patients with choledocholithiasis.

Laparoscopic CBD exploration and the long-term effect of ante-grade biliary stents

Primary closure of common bile duct (CBD) after laparoscopic common bile duct exploration (LCBDE) is now becoming the preferred technique for closure of choledochotomy. Primary CBD closure not only circumvents the disadvantages of an external biliary drainage but also adds to the advantage of LCBDE. Here, we describe our experience of primary CBD closure following 355 cases of LCBDE in a single surgical unit at a tertiary care hospital. All patients undergoing LCBDE in a single surgical unit were included in the study. Preoperative and intraoperative parameters including the technique of CBD closure were recorded prospectively. The postoperative recovery, complications, hospital stay, antibiotic usage, and postoperative intervention, if any, were also recorded. Three hundred fifty-five LCBDEs were performed from April 2007 to December 2018, and 143 were post-endoscopic retrograde cholangiopancreatography failures. The overall success rate was 91.8%. The mean operative time was 98±26.8 minutes (range, 70 to 250 min). Transient bile leak was seen in 10% of patients and retained stones in 3 patients. Two patients required re-exploration and 2 patients died in the postoperative period. Follow-up ranged from 6 months to 10 years, with a median follow-up of 72 months. No long-term complications such as CBD stricture or recurrent stones were noted. Primary closure of CBD after LCBDE is safe and associated with minimal complications and no long-term problems. The routine use of primary CBD closure after LCBDE is recommended based on our experience.

Single-stage laparoscopic management of choledocholithiasis: An analysis after implementation of a mastery learning resident curriculum

BackgroundThere has been a shift in the management of choledocholithiasis from laparoscopic common bile duct exploration to endoscopic retrograde cholangiopancreatography. This has led to an increase in hospital length of stay, costs, and specifically for rural hospitals, transfer to a tertiary center for ERCP. Given this shift of choledocholithiasis management to advanced GI endoscopists, general surgery residents are rarely performing laparoscopic transcystic common bile duct explorations.MethodsA retrospective study of 69 consecutive laparoscopic transcystic common bile duct explorations (LCBDE) performed by 2 general surgeons in a rural community over 5years between 2017 and 2022. Primary outcomes included successful duct cannulation, successful stone clearance, instruments used, operative time, and significant complications (pancreatitis, bile leak, bleeding, bile duct injury). Specific technique for laparoscopic transcystic common bile duct exploration is outlined in Appendix 1.ResultsThere was a median age of 54years (Range 17-91). There was successful cannulation in 97% and successful stone clearance in 82% of cases. In the vast majority of cases only a guide wire and biliary balloon dilation catheter were utilized to perform the procedure. Median operative time for laparoscopic cholecystectomy with cholangiogram was 40minutes. Median operative time for laparoscopic cholecystectomy with cholangiogram and transcystic common bile duct explorations was 64minutes (Range 39-168). Therefore, the median time added by performing LCBDE was 24minutes There were no complications during laparoscopic transcystic common bile duct explorations.ConclusionsLaparoscopic transcystic common bile duct exploration can be safely, efficiently, and successfully performed with 0.035-inch Roadrunner PC guidewire, TAUT intraducer and an Advance Biliary Balloon Catheter. In order to shift the management of choledocholithiasis back to the general surgeon to decrease the length of stay and cost, there needs to be a change at the residency training level.

Background: Common bile duct (CBD) stones are identified in 10-15% of patients undergoing surgery for symptomatic cholelithiasis.When choledocholithiasis is suspected preoperatively, it is recommended that endoscopic retrograde cholangiography (ERC) be performed, and if the choledocholithiasis is confirmed, the patient should then undergo endoscopic sphincterotomy (ES).When CBD stones are discovered intraoperatively, the surgeon proceeds with laparoscopic common bile duct exploration (LCBDE), converts the case to open CBD exploration and choledocholithotomy, or leaves the stones in place for postoperative ES and stone extraction.We report here our initial results of laparoscopic transcystic CBD exploration (LTCBDE) in the management of patients with choledocholithiasis.Patients and methods: From October 2009 to June 2012, we performed 320 laparoscopic cholecystectomies for symptomatic gallstone disease at Zagazig University Hospitals.In the present study, intraoperative cholangiography (IOC) was performed in 47 out of 320 (14.7%) patients.It was negative in 5 (10.6%) patients and suggestive of CBD stones in 42 (89.4%)patients.The incidence of choledocholithiasis in our study was 13.12% (42 from 320 patients).Three patients were converted to open surgery directly when CBD stones were detected, and two patients were referred for postoperative ERCP.Laparoscopic CBD exploration (LCBDE) was attempted in 37 patients.In 7 patients laparoscopic choledochotomy was done.In the remaining 30 patients (71.4%)LTCBDE was performed.Results: LTCBDE was successful in 27 out of 30 patients (90%).In three patients, LTCBDE failed and were converted to open surgery.Causes of failure of TCBDE were numerous stones (> 8) in one patient, impacted stones at distal CBD in another patient and intrahepatic displacement of stones in the third patient.The mean operative time was 110 ± 30 minutes.Postoperative complications included pulmonary atelectasis in two elderly patients, deep vein thrombosis in one patient and ileus in one patient.The overall complication rate was 13.3%.There were no deaths.No bile leak was observed in any of our patients and all were discharged within the first 48 hours.The mean recovery time was 8 days (ranging from 7 to 10 days).Time to return to full physical activity was 14±4 days.Follow-up for 6 months to 2 years was possible in 26 patients (86.7%), and no residual stones were found in any of them.Conclusion: CBD stones still occur in about 10-15% of patients undergoing LC. 90% of these patients could be treated successfully using LTCBDE, with no increase in morbidity or mortality; it seems reasonable to remove stones during the laparoscopic procedure to avoid the possibility of postoperative ERCP or conversion to open surgery.The complications, length of hospital stay, and recovery time were similar to outcomes in patients who underwent LC only.We found that multiple or impacted stones are risk factors for conversion to open surgery.The benefits attained by minimally invasive surgery confirm that LTCBDE should become the primary strategy in the vast majority of patients harboring common bile duct stones.

Objective To analyze the application and value of enhanced recovery after surgery(ERAS) in the elderly patients with open cholecystectomy plus common bile duct exploration and laparoscopic cholecystectomy plus common bile duct exploration in the perioperative period. Methods A total of 113 elderly patients undergoing cholecystectomy plus common bile duct exploration were selected from January 2012 to April 2016 in the Inner Mongolia People′s Hospital. All the patients were divided into 60 patients with open cholecystectomy and common bile duct exploration (O-group) and 53 patients with laparoscopic cholecystectomy and common bile duct exploration (L-group) according to random number table method. The two groups of patients were further divided into 4 subgroups by using random number table method, and the ERAS and traditional measures were respectively implemented, namely [L-ERAS group(27 patients), O-ERAS group(30 patients)] and [L-Control group(26 patients), O-Control group(30 patients)]. The O-group underwent open cholecystectomy plus common bile duct exploration, and the L-group underwent laparoscopic cholecystectomy plus common bile duct exploration. The patients in the ERAS group were treated with ERAS, and the control group was treated by traditional method. The operative time, intraoperative blood loss, postoperative exhaust time, the length of postoperative hospital stay, the hospitalization expenese in different groups were compared. Data were processed with t test. Results The operative time of O-Control group was (2.3±0.7) h, the intraoperative bleeding volume was (81.0±77.7) mL, postoperative exhaust time was (3.4±1.0) d, postoperative hospital stay was(12.9±4.0) d. And the operative time of O-ERAS group was(1.9±0.5) h, the intraoperative bleeding volume was (48.0±24.1) mL, postoperative exhaust time was (2.8±0.9) d, postoperative hospital stay was(10.5±4.1) d. Compare with the O-Control group, the latter with less amount of bleeding, the operative time, the time of postoperative exhaust time, the time of post-operative hospitalization were shortened, and the differences were statistically significant(t=-2.008, -2.099, -2.734, -2.233; with P values below 0.05). The hospitalization expenses of the two groups were(22 246.9±13 344.3) , (20 194.4±2 828.2) yuan, the difference was not statistically significant(P>0.05). The operative time of L-Control group was(2.2±0.6) h, the intraoperative bleeding volume was (54.0±32.1) mL, postoperative exhaust time was (2.9±0.9) d, postoperative hospital stay was(7.0±2.0) d, the operative time of L-ERAS group was(1.8±0.5) h, the intraoperative bleeding volume was (37.0±26.3) mL, postoperative exhaust time was(2.4±0.8) d, postoperative hospital stay was(5.7±1.1) d. Compare with the L-Control group, the latter with less amount of bleeding, the operative time, the time of postoperative exhaust time, the time of post-operative hospitalization were shortened, and the differences were statistically significant(t=-2.179, -2.214, -2.197, -2.660; with P values below 0.05). The hospitalization expenses of the two groups were (22 672.6±5 446.9), (22 404.3±8 482.4) yuan, the difference was not statistically significant(P>0.05). Compared with the O-ERAS group, the L-ERAS group with less amount of bleeding , the operative time, the time of postoperative exhaust time, the time of post-operative hospitalization were shortened, and the differences were statistically significant(with P values below 0.05); however, there was no significant difference in hospitalization expenses between the two groups (P>0.05). Conclusions ERAS in elderly patients with cholecystectomy plus common bile duct exploration can promote the rehabilitation of elderly patients after surgery. And laparoscopic cholecystectomy plus common bile duct exploration is more conducive to rapid postoperative recovery, the effect of clinical application is obvious and can be promoted in clinic. Key words: Cholecystectomy; Cholecystectomy, laparoscopic; Aged; Common bile duct; Enhanced recovery after surgery; Perioperative period

Laparoscopic cholecystectomy is now the gold standard procedure for symptomatic gallstone disease. Nevertheless, there are still several controversies such as the need for routine intraoperative cholangiogram (IOC), the indications for and results of early laparoscopic cholecystectomy in the setting of acute cholecystitis and the use of endoscopic retrograde cholangiopancreatography versus laparoscopic common bile duct (CBD) exploration for intraoperatively detected choledocholithiasis. The aim of this study was to investigate some of these controversies. All laparoscopic cholecystectomies carried out at our institution, a secondary referral centre in Adelaide, South Australia, over a 9-month period were prospectively audited. Data were collected regarding indications for surgery, rate of conversion to open operation, use of IOC, rate of choledocholithiasis and complication rate. There were 202 patients, of whom 152 were women and 50 men. Age range was 15-83 years. Sixty-one per cent of emergency operations were for acute cholecystitis. The conversion rate for emergency operations was 20.6% and for elective procedures was 4.2% (P = 0.003). One hundred and eighty-four patients had an IOC performed. Twelve of these patients had choledocholithiasis. Six of these 12 patients had both normal preoperative ultrasound and liver function tests. Four of the patients went on to postoperative endoscopic retrograde cholangiopancreatography, four had successful laparoscopic CBD exploration, two had open CBD exploration and two had their distal CBD filling defects flushed away with normal saline. There was no morbidity associated with performance of the IOC. There were three patients with postoperative bile leak and one with a bile duct injury. Selective IOC would miss a proportion of patients with choledocholithiasis. Early laparoscopic cholecystectomy for acute cholecystitis is associated with a higher conversion rate than elective laparoscopic cholecystectomy. Overall complication rate is low, with 95% of patients having no complications. Laparoscopic CBD exploration is feasible with a reasonable success rate. This can all be achieved at a secondary referral centre staffed by general surgeons.

Laparoscopic common bile duct exploration is commonplace in adults; however, this procedure is not often performed in children. The goal of this study was to evaluate the results of laparoscopic common bile duct exploration in children. Of 50 patients undergoing laparoscopic cholecystectomy, six patients (12%) had obstructing lesions of the common bile duct (CBD). Five children underwent laparoscopic common bile duct exploration, and one child had a preoperative endoscopic sphincterotomy and stone removal. The mean age at laparoscopic CBD exploration was 11.6 years (range, 5-16). The obstructing lesion was visualized by intraoperative cholangiography in all five patients. The mean operative time for laparoscopic cholecystectomy along with CBD exploration was 215 min (range, 160-282). The transcystic laparoscopic CBD exploration was performed using a 7-Fr, multichannel rigid, or 10-Fr flexible fiberoptic cystoscope. The stones were either pushed into the duodenum with the scope or extracted through the cystic duct using a 3-Fr Segura basket. In one patient, a candidial ball disintegrated during an attempt to remove it with the basket. A repeat cholangiogram at the end of each procedure showed an anatomically normal CBD with free flow of contrast into the duodenum. All patients enjoyed a quick recovery. They were started on a regular diet on the same day of surgery and discharged on the 1st or 2nd postoperative day. One patient with sickle cell disease developed a pulmonary infarction and required 5 additional days of hospitalization. One patient developed recurrent choledocholithiasis 6 months after laparoscopic exploration and was treated successfully with endoscopic sphincterotomy and stone extraction. Laparoscopic CBD exploration can be performed safely at the time of the cholecystectomy in children. Endoscopic sphincterotomy before cholecystectomy is not necessary. We recommend laparoscopic CBD exploration for obstructing lesions of the CBD. Endoscopic sphincterotomy should be reserved for recurrent lesions of the CBD after laparoscopic cholecystectomy.

Choledocholithiasis is a common disease of the biliary system. The traditional surgical method for this is to remove the gallbladder, open the common bile duct, remove the stones and place a T-tube in the common bile duct for drainage. Common bile duct exploration usually requires a T-tube. Without a T-tube, there is a risk of bile leakage due to pressure in the bile duct. After the T-tube is placed, patients experience some form of discomfort and inconveniences with daily life, and there is also a risk of accidental detachment, as well as a risk of bile leakage when the T-tube is removed. In severe cases, patients may need to be hospitalized again. With advancements being made in surgical instruments and technology, laparoscopic common bile duct exploration has been widely used. Due to the carbon dioxide pneumoperitoneum, laparoscopic common bile duct exploration requires a long period of time for T-tube sinus formation compared with open surgery. Therefore, the extubation time needs to be prolonged in laparoscopic common bile duct exploration. The use of an internal drainage tube may be used in order to avoid the aforementioned disadvantages. Since 2012, the authors have performed laparoscopic common bile duct exploration with the placement of an internal drainage tube for the treatment of common bile duct stones, and have completed >160 surgeries. The present study provides a summary of the data of these 160 cases. The 160 patients underwent laparoscopic cholecystectomy. Following the removal of the stones, an internal drainage tube was placed, and the common bile duct incision was primary sutured. All patients were discharged, and there were no complications, such as biliary leakage, biliary bleeding and biliary stricture. On the whole, the present study demonstrates that where possible, the placement of an internal drainage tube in laparoscopic common bile duct exploration is safe and reliable, and may be used to avoid the risk of bile leakage without a T-tube, any inconveniences for patients, and the risk of bile leakage following the removal of the T-tube.

Objective To investigate the clinical efficacies of free endoscopic nasobiliary drainage (ENBD) in primary duct closure (PDC) following laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis. Methods The retrospective cohort study was conducted. The clinical data of 312 patients with extrahepatic bile duct stones accompanied with or without cholecystolithiasis who were admitted to the 11 medical centers [86 in the Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 62 in the Second Affiliated Hospital of Zhejiang University School of Medicine, 44 in the West China Hospital of Sichuan University, 29 in the First Affiliated Hospital of Xi′an Jiaotong University, 27 in the First Hospital Affiliated to Army Medical University (Third Military Medical University), 25 in the Hunan Provincial People′s Hospital, 17 in the Beijing Friendship Hospital of Capital Medical University, 10 in the First Affiliated Hospital of Hainan Medical University, 5 in the Henan Provincial People′s Hospital, 4 in the Beijing Tian Tan Hospital of Capital Medical University, 3 in the First Affiliated Hospital of Fujian Medical University] from January 2011 to June 2017 were collected. All patients underwent LCBDE+ PDC, and 81 and 231 patients with and without ENBD were respectively allocated into the ENBD group and PDC group. Observation indicators: (1) comparisons of operation situations; (2) comparisons of postoperative recovery; (3) comparisons of postoperative complications; (4) follow-up situations. Follow-up using outpatient examination and telephone interview was performed to detect the postoperative complications up to June 2017. Measurement data with normal distribution were represented as ±s. Comparison between groups was analyzed by the t test. Measurement data with skewed distribution were represented M [interquartile range (IQR)], and comparison between groups was analyzed by the nonparametic test. Comparisons of count data were analyzed using the chi-square test and Fisher exact probability. Results (1) Comparisons of operation situations: all the 312 patients underwent successful laparoscopic LCBDE + PDC, without conversion to open surgery, including postoperative death of 1 patient in the PDC group. The common bile duct diameter, cases using interrupted sutures, continuous sutures, absorbable threads and non-absorbable threads were respectively (1.2±0.4)cm, 106, 125, 195, 36 in the PDC group and (1.1±0.5)cm, 76, 5, 79, 2 in the ENBD group, with statistically significant differences between groups (t=2.497, χ2=56.706, 8.457, P 3 mm), normal and abnormal Oddi sphincter contraction function, volume of intraoperative blood loss and operation time were respectively 2.1±1.7, (1.1±0.6)cm, 148, 83, 226, 5, 20 mL (10-45 mL), (116±49)minutes in the PDC group and 1.9±1.6, (1.0±0.6)cm, 49, 32, 75, 6, 20 mL (15-30 mL), (113±23)minutes in the ENBD group, with no statistically significant difference between groups (t=1.021, 0.329, χ2=0.329, 3.428, Z=1.147, t=0.521, P>0.05). The further analysis: of 312 patients, cases and time using interrupted sutures and continuous sutures were respectively 182, 130 and (133±49)minutes, (103±34)minutes, with a statistically significant difference between groups (t=-6.605, P 0.05). Of 312 patients, cases, operation time, volume of intraoperative blood loss and postoperative complications using absorbable threads and non-absorbable threads were respectively 274, (116±44)minutes, 20 mL (15-40 mL), 33 and 38, (115±35)minutes, 18 mL (10-26 mL), 6, with no statistically significant difference between groups (Z=0.971, t=0.023, χ2=0.154, P>0.05). (2) Comparisons of postoperative recovery: recovery time of gastrointestinal function, time of abdominal drainage-tube removal, using time of antibiotics and duration of hospital stay were respectively (2.0±1.5)days, (4.0±2.4)days, (4.0±2.8)days, (5.5±3.0)days in the PDC group and (4.0±1.9)days, (6.9±3.5)days, (10.0±3.9)days, (11.1±3.7)days in the ENBD group, with statistically significant differences between groups (t=-9.507, -8.258, -15.103, -13.575, P 0.05). (4) Follow-up situations: of 312 patients, 252 were followed up for 2-67 month, with a median time of 15 months, including 175 in the PDC group and 77 in the ENBD group. During the follow-up, there was no occurrence of jaundice, cholangitis and pancreatitis, and stone recurrence and postoperative cholangiostenosis were not detected by abdominal color Doppler ultrasound or CT or magnetic resonanced cholangio-pancreatography. Conclusion On the basis of grasping operative indication strictly, ENBD in PDC following LCBDE for choledocholithiasis is safe and effective. Key words: Choledocholithiasis; Common bile duct exploration; Primary duct closure; Laparoscopy; Endoscopic nasobiliary drainage; Multicenter; Retrospective study

Increasingly, laparoscopic biliary surgeons are undertaking laparoscopic cholecystectomy and laparoscopic common bile duct exploration for patients with cholelithiasis and choledocholithiasis. In laparoscopic common bile duct exploration a flexible choledochoscope is ordinarily used, and with this instrument the surgeon usually fails to remove large impacted stones. In contrast with use of a rigid nephroscope it is possible to remove all common bile duct stones irrespective of size and degree of impaction. The present study evaluates the efficiency of rigid nephroscope for managing common bile duct stones laparoscopically. In the present study laparoscopic common bile duct exploration for stones was performed in 80 patients via standard laparoscopic cholecystectomy port sites. Patients with a common bile duct diameter >10 mm were included in this study. The rigid nephroscope was passed through the epigastric port and negotiated into the common bile duct through a choledochotomy. Stones were removed with graspers. Large hard stones were fragmented by pneumatic lithotripsy. Of the 80 patients treated in this manner, 72 (90%) had multiple common bile duct calculi, and 8 (10%) had a solitary common bile duct calculus. Mean common bile duct diameter was 15.3 mm (range: 10-37 mm). Conversion to open common bile duct exploration was necessary in 1 case (1.25%) because of difficult dissection secondary to extensive dense adhesions. In 7 patients (8.75%) a pneumatic lithotripter was used to fragment stones. Choledochotomy was managed by placing a T-tube in 21 (26.25%) patients, by effecting primary closure in 58 (72.5%) patients, and by choledochoduodenostomy in 1 (1.25%) patient. The mean operative time in this series was 83 min (range: 53-135 min). The mean postoperative hospital stay was 4.2 days (range: 3-19 days). One patient (1.25%) developed cholangitis 5 months after laparoscopic common bile duct exploration; the cause was a residual common bile duct stone. A rigid nephroscope can be used for managing all types of common bile duct calculi irrespective of site, size, composition, or degree of impaction. Its use can be expected to become the standard for laparoscopic common bile duct exploration, especially for removing large calculi from a dilated common bile duct.

Objective To compare the efficacy and safety of laparoscopic common bile duct exploration (LCBDE) combined with primary suture in elderly and younger patients with choledocholithiasis. Methods From May 2012 to February 2017, 81 cases of choledocholithiasis who were treated in our hospital by LCBDE combined with primary suture were collected retrospectively. They were divided into two groups according to their age, the aged group (≥ 65 years old) and the younger group (<65 years old). Clinical data of the two groups were statistically analyzed by SPSS22.0 software. The measurementdata of perioperative period were expressed as (±s) and compared with independent t test. The incidence of postoperative complications and the data of follow-up were counted in case (%) and compared with fisher test, the difference was statistically significant in P<0.05. Results All the 81 patients had successfully completed operation and had no conversion to open surgery. There was no significant difference in operative time and intraoperative bleeding volume (all P>0.05). Compared with the younger group, the time of postoperative abdominal drainage, the time of getting out of bed, the time of recovery of gastrointestinal function and the duration of hospitalization were significantly prolonged in the elderly group. (all P 0.05). There was one case of residual stone in the elderly group after operation and no recurrence of stone occurred in both groups. Conclusion Laparoscopic exploration of common bile duct combined with primary suture is effective, safe and feasible. The postoperative complications and recurrence of stones are similar to those of young and middle-aged patients, which is suitable for the elderly patients with choledocholithiasis under the strictly surgery indications. Key words: Choledocholithiasis; Laparoscopy; Aged; Suture Techniques; Comparative Effectiveness Research

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.