Surg Clin N Am 88 (2008) 1315–1328

Common Bile Duct Exploration

for Choledocholithiasis
Jennifer E. Verbesey, MD,
Desmond H. Birkett, MB, BS, FACS*
Department of General Surgery, Lahey Clinic Medical Center,
Tufts University School of Medicine, 41 Mall Road, Burlington, MA 01805, USA

Common bile duct stones represent a significant danger to patients,

because they can lead to biliary colic, obstructive jaundice, cholangitis, or
pancreatitis. Common bile duct stones either migrate from the gallbladder
or form primarily within the bile ducts themselves. Primary stones are
more common in South Asia and are usually sequelae of biliary infection
and stasis. In the United States and other Western countries, common
bile duct stones are predominantly secondary stones, having formed in the
gallbladder. In patients who have gallstones, and in whom a cholecystectomy
is considered, common bile duct stones can be found preoperatively, intra-
operatively, or postoperatively. Ten percent to 15% of patients undergoing
a cholecystectomy will be found to have choledocholithiasis at some point
during their treatment [1–6]. Of these patients, it is estimated that approxi-
mately one third may pass the obstructing common duct stone within
2 months with no intervention [7]. The remainder will require an endoscopic
or surgical intervention to relieve the obstruction. Because, at this time, it is
impossible to predict into which group a patient will fall, it generally is ac-
cepted that in all situations where common bile duct stones are either sus-
pected or confirmed, extraction should be performed.

Preoperative diagnosis and treatment

Choledocholithiasis is suspected preoperatively in those patients who
have elevated liver function studies, jaundice, pancreatitis, radiologic signs

* Corresponding author.
E-mail address: [email protected] (D.H. Birkett).

0039-6109/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.suc.2008.08.002 surgical.theclinics.com
1316 VERBESEY & BIRKETT

of dilated intra- or extrahepatic ducts, or evidence of common bile duct

stones by ultrasound. The most direct method of dealing with choledo-
cholithiasis preoperatively is by endoscopic retrograde cholangiopancrea-
tography (ERCP). ERCP first was reported in 1974 and has gained
widespread usage. Decompression of the ductal system can be achieved
by means of endoscopic removal of stones with or without sphincterot-
omy. This procedure has a reported success rate of 70% to 90% [8].
A normal examination, however, will be encountered in 40% to 60% of
cases where common bile duct stones are suspected. Therefore, sphincter-
otomy should be reserved for those patients in whom there is good evi-
dence that a stone is present in the common bile duct. Certainly, ERCP
has its share of complications that need to be considered in the deci-
sion-making process. Published rates for morbidity from ERCP are ap-
proximately 5% to 19%, and mortality has been reported at 0% to
2.3% [8]. The use of magnetic resonance cholangiopancreatography
(MRCP) to help select the patients who would benefit most from
ERCP is discussed later in this article.
ERCP is an excellent therapeutic option in those centers where the equip-
ment and experienced, qualified endoscopists are readily available, but it
does add an extra procedure for the patient, which reduces the effectiveness
and efficiency of a laparoscopic approach. Because the published morbidity
rates for ERCP and laparoscopic common bile duct exploration are roughly
equivalent, ERCP plus or minus sphincterotomy is a good starting point in
patients in whom stones are known to be present or strongly suspected, and
a laparoscopic cholecystectomy is planned. A recently published Cochrane
meta-analysis concluded that, in past years, when open cholecystectomies
were common, open common bile duct exploration was superior to
ERCP. In the laparoscopic era, however, laparoscopic exploration and
ERCP have very similar success and morbidity rates associated with
common bile duct clearance [9].

Intraoperative diagnosis and treatment

If the patient has a history of elevated liver function tests or biliary pan-
creatitis preoperatively, it is important to perform an intraoperative cholan-
giogram to rule out persistent common bile duct stones. If stones are found
during the course of a laparoscopic cholecystectomy, there are three ways of
proceeding: laparoscopic common bile duct exploration (LCBDE), conver-
sion to an open common bile exploration (CBDE), or completion of the
cholecystectomy with postoperative ERCP. The inherent risk of the last op-
tion is that if ERCP is unsuccessful at retrieving the impacted stone, the pa-
tient will need to return to the operating room for yet another procedure. If
the patient is undergoing an open cholecystectomy, then it is most logical to
continue with an open common bile duct exploration.
 COMMON BILE DUCT EXPLORATION 1317

Postoperative diagnosis and treatment

Occasionally, the patient will have no signs of common bile duct obstruc-
tion and a normal cholangiogram intraoperatively (or one is not per-
formed), yet develop signs of choledocholithiasis postoperatively. Most
frequently this is because of a stone being pushed down from either the gall-
bladder or cystic duct into the common bile duct in the course of performing
a laparoscopic cholecystectomy. Because the surgery is already complete,
the most sensible option for the patient is to undergo ERCP plus or minus
sphincterotomy to deal with the problem.

Preoperative imaging
Radiologic assessment of the bile ducts has improved in the past de-
cade. Transabdominal ultrasound often is used as a screening test for com-
mon bile duct stones; however, it is not extremely sensitive (sensitivity 0.3,
specificity 1.00) [10–12]. In combination with clinical symptoms and labo-
ratory abnormalities, ultrasound examination can help select the patients
who need further imaging. With high specificity, if an ultrasound is nega-
tive and liver function tests are normal, there is a very small likelihood of
common duct stones [12]. CT scans are commonplace, particularly in the
emergency room workup of patients, and have been quoted as having sen-
sitivity between 65% and 93%, and a specificity of 84% to 100% (Fig. 1)
[13–15]. Better options include MRCP, with a sensitivity and specificity of
greater than 90% [13,16–18] (Fig. 2), or endoscopic ultrasound (EUS),
also with a sensitivity and specificity of greater than 90% (Fig. 3). All
of these studies are purely diagnostic, whereas ERCP has the advantage
of being both diagnostic and possibly therapeutic at the same time. Given
the complication risk of ERCP, however, these other preoperative screen-
ing tools can be very helpful to select out those patients who would benefit
most from ERCP.

Indications for common bile duct exploration

Common bile duct exploration is done based on the results of an intrao-
perative cholangiogram (IOC) or sonogram. Some surgeons advocate for
IOC in every patient, because they would argue that, in addition to demon-
strating the presence of common bile duct stones, it provides a map of the
anatomy and decreases the incidence of bile duct misadventures. On the
other hand, many feel that with a good preoperative history, appropriate
laboratory tests, and preoperative imaging, extra biliary manipulation is un-
necessary. For this group, indications for intraoperative cholangiogram in-
clude the history or presence of any of the following:
History of elevated liver function tests
History or presence of jaundice
1318 VERBESEY & BIRKETT

Fig. 1. CT scan demonstrating dilated cystic and common bile duct. Gallstone is seen in
common bile duct.

Fig. 2. Magnetic resonance cholangiopancreatography image documenting presence of stone in

distal common bile duct. An endoscopic retrograde cholangiopancreatography later verified
that finding, and the patient underwent a successful sphincterotomy.
 COMMON BILE DUCT EXPLORATION 1319

Fig. 3. Endoscopic ultrasound demonstrating common bile duct stone. Ultrasound probe is lo-
cated in the duodenum, and multiple stones can be seen in the duct, causing shadowing distally.

Biliary pancreatitis
Radiographic evidence of a dilated ductal system
Radiographic visualization of common bile duct stones
Contraindications for laparoscopic or open exploration include an inex-
perienced surgical team not comfortable with the procedure or lack of nec-
essary equipment.

Open common bile duct exploration

The first open common bile duct exploration was described in 1889 by
New York surgeon Robert Abbé. He opened the duct of a 36-year-old
woman with severe jaundice, removed a stone, sewed the duct closed with
fine silk, and returned her to perfect health. Other sources give credit for
the first exploration to Londoner J.K. Thornton, Swiss surgeon Ludwig
Courvoisier, or Herman Kümmell of Hamburg, Germany [19].
Although very rare today given the success of stone removal by means of
endoscopic or laparoscopic techniques, there are still several indications for
proceeding with an open bile duct exploration. The most obvious example is
those patients who are undergoing another open abdominal procedure or an
1320 VERBESEY & BIRKETT

open cholecystectomy because of concomitant problems or past surgeries,

making a laparoscopic approach very difficult. In addition, some patients
will undergo an open exploration because of conversion of a laparoscopic
procedure to an open one. A relative indication for open exploration is large
or multiple stones or the need to perform a transduodenal sphincteroplasty.
Finally, open common bile duct exploration still is considered the gold stan-
dard for the removal of common bile duct stones. If the surgical team does
not have the experience or feels uncomfortable with the laparoscopic
approach, or qualified endoscopists are not available, an open technique
should be employed.
The common bile duct is exposed in the free border of the lesser omen-
tum, above the duodenum. If this is difficult because of dense adhesions
or inflammation, a small needle can be used to aspirate bile from the struc-
ture thought to be the bile duct to confirm the anatomy. In addition, a trans-
cystic intraoperative cholangiogram can be very helpful in verifying the
anatomy. Two stay sutures using 4-0 chromic stitches are placed on either
side of the planned bile duct incision. An anterior, vertical choledochotomy
is made. Great care should be taken to not injure the posterior wall of the
duct when making the initial incision. Some surgeons alternatively will place
the stay sutures after making the incision.
The first tactic to remove the stones is flushing of the duct. A small red
rubber catheter attached to a saline syringe is placed distally into the
duct. The distal duct is irrigated, and small stones often will float back
toward the choledochotomy and out. If the saline injection is not returning
out the incision, the catheter is too far in and past the sphincter. At this
point, some surgeons will flush the proximal duct, but more frequently
this is avoided because of the fear of pushing small stones further up into
small hepatic radicals, where they can become very difficult to dislodge.
A Fogarty balloon catheter, with the balloon deflated, is passed distally
through the choledochotomy and advanced distally into the duodenum.
The balloon is inflated, and the catheter is withdrawn until resistance is
felt at the sphincter of Oddi (Fig. 4). At that point, the balloon is deflated,
tension on the catheter released, and the catheter withdrawn a small amount
and then reinflated; this is repeated until the catheter is just above the
sphincter. The catheter is then gently completely withdrawn, hopefully
bringing out any remaining stones with it through the choledochotomy
(Fig. 5). The catheter then is passed proximally to retrieve any proximal
stones also (Fig. 6) [20].
After attempting to clear the duct with irrigation and balloon catheters,
direct vision using a flexible fiber choledochoscope needs to be performed. If
a stone is seen using the choledochoscope, then a retrieval basket is passed
through the instrument channel of the choledochoscope, passed beyond the
stone, opened, and gently and slowly pulled back to ensnare the stone. Once
caught in the basket, it is closed under direct vision, and the choledocho-
scope and basket are removed from the common bile duct. The older rigid
 COMMON BILE DUCT EXPLORATION 1321

Fig. 4. After flushing, an initial attempt to dislodge a stone is done by passing a Fogarty bal-
loon catheter though the choledochotomy into the duodenum. The balloon then is inflated and
withdrawn until resistance is felt at the Sphincter of Oddi.

instruments, such as Randall stone forceps or scoops, have no place today,

as they can cause injury to the bile duct and sphincter.
There may be instances where an impacted stone remains despite all of
these described methods of dislodgement. In these difficult cases, intracor-
poreal electrohydraulic or laser lithotripsy can be attempted under direct vi-
sion, washing the fragments through into the duodenum. This is often not
available, however; if it is, it must be done very cautiously, as it is easy to
cause ductal injury.
If all of the previously mentioned maneuvers fail, the final step is to
perform a transduodenal sphincterotomy. The duodenum is kocherized (dis-
sected medially) and the area palpated to localize the stone. If the stone
cannot be felt, a Fogarty catheter or probe can be placed through the chole-
dochotomy and passed down toward the duodenum as a landmark for the
sphincter. A 2 to 4 cm duodenotomy incision is made on the anterior wall
of the second portion of the duodenum opposite the stone or probe. Inter-
nally, the ampulla should be visualized. Two traction sutures are placed in
the duodenal mucosa at both ends of the incision so the duodenal wall can
be everted and better exposure to the ampulla obtained. A sphincterotomy
1322 VERBESEY & BIRKETT

Fig. 5. When resistance is felt at the Sphincter of Oddi, the balloon is deflated, withdrawn
a small amount and then reinflated. The balloon at this point should be positioned just above
the sphincter. The Fogarty catheter then is withdrawn completely, bringing with it any stones it
catches through the choledochotomy.

is performed at the 10 o’clock position, which should be directly opposite the

most common position for the pancreatic duct [20]. The incision is made down
onto the stone or probe. After the stone is extracted successfully, the sphinc-
terotomy incision is matured with vicryl sutures to approximate the common
bile duct mucosa with the duodenal mucosa. A catheter should be passed
through the sphincter at the conclusion of this maneuver to verify its patency.
The duodenotomy then is closed in two layers with vicryl and silk. Finally,
a T-tube is place through the choledochotomy site, and the incision is closed
with interrupted 4-0 vicryl sutures. Absorbable sutures always should be used
in the bile duct, because the suture material can be lithogenic. The benefits of
T-tube placement are maintaining ductal patency in the setting of edema and
providing easy access for postoperative imaging.
In 2 to 3 weeks, a repeat cholangiogram is obtained through the T-tube.
If this study is normal, the T-tube can be removed. An alternative treatment
plan for a patient who has an impacted stone is to place a T-tube to drain
the duct, and 4 weeks later, when the edema associated with the impaction
has settled, the stones are extracted through the T-tube tract.
 COMMON BILE DUCT EXPLORATION 1323

Fig. 6. After clearing the distal duct, the Fogarty catheter can be passed proximally to retrieve
any proximal stones. Prior to this, some surgeons will flush the proximal ducts, but this fre-
quently is avoided so that smaller stones will not be pushed up into small hepatic radicals.
The catheter is withdrawn, hopefully pulling down any proximal stones out through the
choledochotomy.

Laparoscopic common bile duct exploration

Because over 80% of gallbladders are removed laparoscopically, laparo-
scopic common bile duct exploration is being performed with increasing fre-
quency. It is a difficult procedure, however, that requires a great deal of
laparoscopic skill. Therefore it only is done by a select group of laparoscopic
surgeons. The advantages are clear; the gallbladder and stones are taken care
of simultaneously in a minimally invasive manner that leads to shorter hos-
pital stays and less pain than the corresponding open procedure or
laparoscopic cholecystectomy/ERCP combination. Still, laparoscopic com-
mon bile duct exploration has its own share of complications, and morbidity
rates are quoted between 2% to 17%. Reported mortality rates are 1% to 5%
[9]. Compared with the 4% to 20% mortality rates long quoted for open elec-
tive and emergency procedures in patients over 70 years old [21–24], there
may be a great advantage if laparoscopic techniques are successful.
Laparoscopic common bile duct exploration can be achieved by means of
two methods: transcystic or choledochotomy. If technically feasible, the
1324 VERBESEY & BIRKETT

transcystic approach is the preferred method, because it is the least invasive

option, the quickest, and the least expensive. This approach, however, only
will be successful for smaller stones and a duct that can be dilated to accept
a 9 or 10 Fr diameter choledochoscope. Other factors that will dictate which
approach is used include the presence and location of multiple stones, the
anatomy of the cystic duct in relation to the common bile duct, the degree
of inflammation in the surrounding areas, and the ability of the surgeon to
complete a complex laparoscopic procedure that includes intracorporeal
suturing of a small structure [8].
It is most important to first gather all of the equipment that may be
needed during the procedure. The critical items include the following:
Second video camera
Cholangiogram catheter
Pneumatic dilators
4 or 5 Fr Fogarty balloon catheter
Stone extractor basket
T-tube
Flexible choledochoscope
Glucagon 1 mg
Most surgeons will use fluoroscopic imaging as their method of intrao-
perative imaging; however, percutaneous cholangiography and intraopera-
tive ultrasonography also can be used. If fluoroscopic guidance will be
used, it is also necessary to ensure a C-arm fluoroscope is in the operating
room and a person capable of operating it is available.
The procedure starts with dilatation of the cystic duct if necessary. The
cystic duct frequently already is dilated from the passage of stones into
the common bile duct or small bowel. If not, a guidewire is placed through
the cystic duct and advanced until it is in the common duct. Pneumatic
dilators are inserted over the wire until the cystic duct is capable of accepting
a 9 or 10 Fr choledochoscope, but not greater than 8 mm [25]. A 3 mm scope
can be used for the procedure, but a 5 mm one is preferable because of better
illumination and the access for larger instruments it provides.
If the transcystic approach is not going to provide adequate access, a chol-
edochotomy is performed, provided that the common bile duct is dilated. This
method of access is indicated for patients who have larger or multiple stones,
proximally located stones, anatomy not conducive to the transcystic ap-
proach, or after a failed attempt transcystically. Two stay sutures on the com-
mon bile duct are optional [25]. An incision is made longitudinally, avoiding
the common bile duct blood supply at the 3 and 9 o’clock positions. This
can be performed using a laparoscopic scissors. The incision needs to be at
least as long as the largest stone (usually approximately 1 cm). Care should
be taken not to make the incision too large, as this will result in a longer
and more difficult closure with intracorporeal suturing.
 COMMON BILE DUCT EXPLORATION 1325

Whether through the cystic duct or the common bile duct, the remainder
of the procedure is performed in a similar fashion. The first technique used
to try to remove any stones is to irrigate the common bile duct using normal
saline. This only will be successful for very small stones (!3 mm) or sludge.
As an adjunct measure, the surgeon can ask the anesthesiologist to give the
patient 1 mg of intravenous glucagon to relax the sphincter of Oddi and in-
crease the chances of success [8]. Success or failure should be documented by
choledochoscopy.
If the stones remain after flushing, the surgeon should proceed to trying
to dislodge them using balloon Fogarty catheters. The balloon catheter is
placed through the sleeve in the abdominal wall and inserted into the
common duct, either by means of the cystic duct or through the choledo-
chotomy. An endoscopic forceps can be used in the other hand to facilitate
this step. The balloon catheter is advanced as far as possible, ideally into the
duodenum. The balloon then is inflated and slowly withdrawn until resis-
tance is felt. This should represent the balloon meeting the sphincter. At
this point, the tension on the catheter should be released, the balloon
deflated, the catheter withdrawn slightly, and the balloon reinflated to see
if it is above the sphincter. This maneuver is repeated until the balloon is
just above the sphincter and below a stone. With slow, deliberate with-
drawal of the balloon catheter, small stones may be extracted through the
cystic duct or choledochostomy.
If larger stones still remain despite these procedures, several other tech-
niques may be employed. First, a choledochoscope may be used in combina-
tion with the balloon catheters, because direct visualization may increase the
chance of success. Second, baskets can be used to try to capture the stones di-
rectly. The basket is inserted through the instrument channel or operating port
of the choledochoscope into the common bile duct. The basket is advanced
past the stone under direct vision, opened, and withdrawn to ensnare the
stone. The basket is closed carefully to entrap the stone, and then the choledo-
choscope, basket, and stone are removed from the common bile duct. Confir-
mation of a clear duct should be made with choledochoscopic visualization.
If the stone is large or impacted, all of these maneuvers may fail, and lith-
otripsy can be tried or a T-tube placed and the stone removed postopera-
tively. Frequently, the choledochoscope will have limited usage through
the cystic duct, because the anatomy will not allow the scope to turn and
advance into the proximal duct. If this poses a problem, the incision in
the cystic duct can be lengthened down to the junction of the cystic and
common bile ducts. If the stone is visualized, a combination of flushing,
balloon catheter use, and basket retrieval under direct visualization may
be successful. There have been various attempts at the usage of lithotripsy
at this juncture to destroy the stones and flush the fragments from the
duct. This is difficult to do within a small duct, however, and has a relatively
large risk of ductal damage; therefore it is not performed frequently [8].
1326 VERBESEY & BIRKETT

Whenever it is felt that the common bile duct has been cleared of all
stones, and no further manipulations are anticipated, it is important to
shoot a completion cholangiogram documenting the free flow of contrast
through the common bile duct into the duodenum, in addition to no new
abnormalities in anatomy.
If a transcystic approach was used, the cystic duct needs to be ligated
with clips and divided. If a choledochotomy was performed, it can be closed
primarily with no drainage, or a biliary stent (T-tube), placed into the
duodenum through the choledochotomy, can be used to protect the primary
repair. Closure with T-tube drainage is the preferable and safer closure. The
indications for T-tube drainage are [8]:
Decompression of the common bile duct if outflow obstruction due to
residual stones or edema
Ability to obtain T-tube cholangiogram for postoperative visualization of
ducts
Access for removal of residual stones

To place the T-tube, a small section of the back of the T is cut out, and the
T-tube is placed into the common duct through the choledochotomy. The
remainder of the common bile duct opening then is closed with a 4-0 or
5-0 absorbable suture with intracorporeal laparoscopic suturing and knot
tying. It is important to use absorbable suture, because other sutures can
be lithogenic. After placement of the T-tube, which is brought out through
one of the trocar sites, a completion cholangiogram must be performed. The
T-tube is tested by pushing fluid through it and verifying there is no leak. If
a T-tube is not going to be used, the entire choledochotomy is closed primar-
ily with the same suture. A T-tube cholangiogram is obtained before remov-
ing the tube 2 weeks after surgery.
The risks of T-tube placement include increased morbidity or mortality
secondary to biliary infection, migration of the tube causing bile duct ob-
struction, or bile duct leaks or peritonitis after removal. To prevent the lat-
ter two complications, the T-tube must not be pulled up tightly to the
abdominal wall, and the T-tube must not be removed for at least 2 weeks
postoperatively. A 2007 Cochrane review found insufficient evidence to rec-
ommend T-tube drainage over primary closure or vice versa [26].
Laparoscopic common bile duct exploration has a high success rate, with
rates reported from 83% to 96% in recent years (93.3% in 2008 Cochrane
Review) [9]. The morbidity rate has been reported to be approximately
10% and includes minor complications such as: nausea, vomiting, diarrhea,
fever, and urinary retention. Major complications, defined as those that
require further procedures, include: wound infections, biliary leaks, abscess
formation, subhepatic fluid collections, T-tube complications, and pulmo-
nary, cardiac, or renal failure. Mortality rates are very low, at less than 1%.
 COMMON BILE DUCT EXPLORATION 1327

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