Retained stone after laparoscopic common bile duct exploration and failed choledochoscopy – now what? Case report

Common bile duct exploration (CBDE) is a surgical technique that has become a lost art in everyday practice due to the wide availability of endoscopic retrograde cholangiopancreatography (ERCP). Residents nowadays have very poor exposure to this procedure, and even less so to laparoscopic CBDE (LCBDE). Such lack of exposure is unfortunate, because after ERCP the patient will still require laparoscopic cholecystectomy (LC). As a result, the patient will have to undergo two procedures instead of one and will require paid sick leave twice. Besides, the cost of ERCP + LC is also higher than that of LCBDE. Many studies have shown similar outcomes and similar complication rates of LCBDE when compared to ERCP + LC. One of the challenges associated with LCBDE is the relatively demanding training and limited exposure to the procedure, mainly due to the lack of suitable patients, as ERCP is usually preferred. Additionally, LCBDE requires advanced laparoscopic skills to perform successfully. Although LCBDE has similar rates of stone clearance compared to ERCP (97%), there are still cases where a stone is left behind. Then an additional procedure is performed, and the cost of treatment is higher. There are several ways to resolve the issue, with different approaches appropriate for different patients. The skill level of the surgeon and his familiarity with the procedure also play an important role in the decision making. Choledochoscopy, T-tube placement, stenting and ERCP or conversion to open surgery are some of the available options for management of retained stones after LCBDE. We present a case of LCBDE with a retained stone, failed choledochoscopic extraction and an example of successful laparoscopic stone clearance without conversion or the need of an endoscopic procedure.