Common bile duct exploration: Transcystic versus transcholedochal approach

Purpose: Choledocholithiasis can be treated by either open, laparoscopic, percutaneous, or endoscopic approach (Endoscopic Retrograde Cholangiopancreatography [ERCP]). In experienced hands, the laparoscopic common bile duct exploration is an advantageous option for managing stones within the biliary tree with the benefits of a single stage approach and high success rates. Although, it is not clear whether laparoscopic transcystic exploration is superior than a transcholedochal one in the management of choledocholithiasis. Aim: To compare the safety and effectiveness of transcystic with transcholedochal approach in laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis. Methods: Observational, retrospective study of patients undergoing LCBDE between January 2012 and May 2020. Descriptive and statistical analysis was performed with SPSS 25. Results: 172 patients underwent LCBDE (42.4% male, median age 63.5 years). Transcystic exploration was chosen in 58.7% and transcholedochal in 41.3% of patients. In the transcholedochal approach, the majorly of the patients had dilatated CBD. Complication rates were similar in both groups. The CBD stone clearance rate was higher in the transcystic exploration. Additionally, 14% of the patients with the transcystic approach underwent postoperative ERCP, similarly to those in transcholedochal treatment. Conclusion: From our knowledge both options are valid and safe. Transcystic exploration is feasible in most cases, saves time, does not violate de CBD and shows no higher morbidity. Once stones exceed 5mm, the likelihood of extraction falls and a choledochotomy may be a better one. Furthermore transcholedochal exploration has a higher rate of successful duct clearance.