الفهرس 
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Abstract
About 40 years ago, common bile duct (CBD) stones were managed only with open choledocholithotomy. The ensuing decades carried two major revolutions in management of gallstone disease that provided physicians and surgeons with multiple options and alternatives in their care of patients. These were the development of endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and laparoscopic cholecystectomy (LC) with the possibility to explore and clear the CBDCurrently, the options for management of preoperatively suspected choledocholithiasis include (1) preoperative ERCP, endoscopic sphincterotomy (ES), and stone extraction followed by LC; (2) transcystic cholangiography followed by transcystic or direct CBD exploration; (3)postoperative ERCP with ES and stone extraction; (4) LC combined with intraoperative ERCP, ES and stone extraction, and (5) conversion to open cholecystectomy and CBD exploration.
Compared to staged procedures, single session management of gallbladder stones and CBD stones is safe, effective and less costly. The aim of our study was to compare the success/ failure rate, complication rate, hospital stay and clinical outcome of two minimally invasive techniques used as a single session procedure for management of CBD stones: LC combined with intraoperative ERCP (group A) and LC with laparoscopic CBD exploration (group B).
This study was conducted on 60 patients with a clinical diagnosis of choledocholithiasis recruited from general surgery department, Benha university hospital & the gasrto-intestinal surgical center, Mansoura university. Patients were randomized into two groups as follows:
group A: Underwent laparoscopic cholecystectomy with intraoperative ERCP. (30 patients)
group B: Underwent laparoscopic cholecystectomy with laparoscopic common bile duct exploration. (30 patients)
The results were as follow:
-There were no significant differences between both groups as regard age and gender.
-There were no significant differences between both groups as regard presentation by jaundice, pain and associated comorbidities.
-There were no significant differences between both groups as regard all preoperative laboratory findings.
-Total duration was significantly higher in group B (3.07 hours) compared to group A (1.39 hours)
-There were no significant differences in both groups as regard intraoperative complications including bleeding, blood loss and conversion.
-No cystic duct injury, CBD injury, intestinal perforation and blood transfusion were reported in both groups.
-There was no significant difference between both groups as regard complete clearance.
-Use of drains was significantly higher in group B (100.0%) compared to group A (20.0%).
-There were no significant differences between both groups as regard postoperative jaundice and pain.
-There were no significant differences between both groups as regard all post-operative laboratory findings.
-Mean hospital stay was significantly higher group B (10 days) compared to group A (4 days).
-There were no significant differences between both groups regard postoperative complications with higher incidence of pancreatitis in group A, while group B showed higher incidence of leakage.
Conclusion & Recommendations
In conclusion, the two reported procedures can be used for treating cholelithiasis with CBD stones. However, we recommend the use of intraoperative ERCP as a preferred option for management of patients with gallbladder stones and preoperatively diagnosed CBD stones when facilities for endoscopic therapy are readily available. However, there are some limitations for this study that we hope will be addressed in future studies. The need for long term follow-up, as retained stones often show up some months or years after surgery. We did not use choledochoscopy in any CBD exploration, and we depended only on fluoroscopic guidance. The use of choledochoscopy may increase the success of LCBDE. Finally, the availability of intraoperative ERCP in many centers is limited, and the requirement to have an endoscopist experienced in ERCP available for all cases would be prohibitive; unless the surgeon had this skill (as in this study), this would mean limited applicability. So we recommend that the hepatobiliary surgeon should be acquainted with operative ultrasound, endoscopy and ERCP as the third hand to expand his field of therapeutic options.