Results during the learning curve in the laparoscopic common bile duct exploration for choledocolithiasis.

OBJECTIVES: To analyze the results obtained in terms of efficacy and safety during the learning curve of a surgical team in the technique of laparoscopic common bile duct exploration with cholecystectomy (LCBDE+LC) using choledochoscopy for the treatment of patients with cholelithiasis and choledocolithiasis or common bile duct stones (CBDS) (CDL). METHODS: Single-center prospective analysis of patients treated with LCBDE+LC during the first 4 years of implementation of the technique. A descriptive and comparative analysis was carried out between groups according to the transcystic (TCi) or transcolecocal (TCo) approach, and also evolutionary by periods. The effectiveness of the technique was evaluated using the variable success rate and safety through the analysis of the overall complication rate and the bile leak rate as the most frequent adverse effect. RESULTS: A total of 78 patients were analyzed. The most frequent approach was TCo (62%). The overall success rate was 92%. The TCi group had a shorter operating time, a lower overall complications rate and a shorter hospital stay. The TCo approach was related to a higher rate of clinically relevant bile leak (8%). Complex cases increased significantly during the learning curve without effect on the overall results. CONCLUSIONS: LCBDE+LC is an effective and safe technique during the learning curve. Its results are comparable to those published by more experienced groups and do not present significant differences related to the evolution during learning period.

Obstructive lithiasis of the lower bile duct discovered four decades after cholecystectomy and its management by ideal choledochotomy: a case report.

BACKGROUND: Residual lithiasis is the presence of stones in the common bile duct, ignored after one or more biliary interventions. We report an atypical case of chronic symptomatic lithiasis of the lower bile duct occurring 41 years after biliary surgery, managed successfully by ideal choledochotomy. CASE PRESENTATION: A 68-year-old Black African female with several past laparotomies including a cholecystectomy forty-one years ago presented with hepatic colic-type pain that had been intermittent for several years but worsened recently. Her clinical, biological, and imaging test assessments were suggestive of a residual obstructive lithiasis of the lower common bile duct. Through an open right subcostal laparotomy approach, a dilated bile duct of approximately 3 cm was found and managed by transverse choledochotomy in which the stone was extracted in retrograde manner. After confirmation of disobstruction, a primitive bile duct suture without biliary drainage was performed and a tubular drain was positioned under the liver. The postoperative course was uneventful at follow-up of 30 days. CONCLUSION: Residual choledocholithiasis can be avoided. We performed an ideal choledochotomy, of which the follow-up was simple.

The short- and long-term outcome after the surgical management of common bile duct stones in a tertiary referral hospital.

BACKGROUND: The removal of common bile duct stones by endoscopic retrograde cholangiopancreatography (ERCP) shows excellent results with low complication rates and is therefore considered a gold standard. However, in case of stones non-removable by ERCP, surgical extraction is needed. The surgical approach is still controversial and clinical guidelines are missing. This study aims to analyze the outcomes of patients treated with choledochotomy or hepaticojejunostomy for common bile duct stones. METHODS: All patients who underwent choledochotomy or hepaticojejunostomy for common bile duct stones at a tertiary referral hospital over 11 years were included. The analyzed data contains basic demographics, diagnostics, surgical parameters, length of hospitalization, and morbidity and mortality. RESULTS: Over the study period, 4375 patients underwent cholecystectomy, and 655 received an ERCP with stone extraction, with 48 of these patients receiving subsequent surgical treatment. ERCP was attempted in 23/30 (77%) of the choledochotomy patients pre/intraoperatively and 11/18 (56%) in hepaticojejunostomy patients. The 30-day major complication rate (Clavien-Dindo > II) was 1/30 (3%) in the choledochotomy group and 2/18 (11%) in the hepaticojejunostomy group. Complications after 30 days occurred in 3/30 (10%) patients and 2/18 (11%), respectively, and no mortality occurred. CONCLUSION: ERCP should still be considered the gold standard, although due to low short- and long-term morbidity rates, choledochotomy and hepaticojejunostomy represent effective surgical solutions for common bile duct stones.

A proposed difficulty grading system for laparoscopic bile duct exploration: benefits to clinical practice, training and research.

BACKGROUND: A gap remains between the mounting evidence for single session management of bile duct stones and the adoption of this approach. Laparoscopic bile duct exploration (LBDE) is limited by the scarcity of training opportunities and adequate equipment and by the perception that the technique requires a high skill-set. The aim of this study was to create a new classification of difficulty based on operative characteristics and to stratify postoperative outcomes of easy vs. difficult LBDE irrespective of the surgeon's experience. METHODS: A cohort of 1335 LBDEs was classified according to the location, number and size of ductal stones, the retrieval technique, utilisation of choledochoscopy and specific biliary pathologies encountered. A combination of features indicated easy (Grades I and II A & B) or difficult (Grades III A and B, IV and V) transcystic or transcholedochal explorations. RESULTS: 78.3% of patients with acute cholecystitis or pancreatitis, 37% with jaundice and 46% with cholangitis had easy explorations. Difficult explorations were more likely to present as emergencies, with obstructive jaundice, previous sphincterotomy and dilated bile ducts on ultrasound scans. 77.7% of easy explorations were transcystic and 62.3% of difficult explorations transductal. Choledochoscopy was utilised in 23.4% of easy vs. 98% of difficult explorations. The use of biliary drains, open conversions, median operative time, biliary-related complications, hospital stay, readmissions, and retained stones increased with the difficulty grade. Grades I and II patients had 2 or more hospital episodes in 26.5% vs. 41.2% for grades III to V. There were 2 deaths in difficulty Grade V and one in Grade IIB. CONCLUSION: Difficulty grading of LBDE is useful in predicting outcomes and facilitating comparison between studies. It ensures fair structuring and assessment of training and progress of the learning curve. LBDEs were easy in 72% with 77% completed transcystically. This may encourage more units to adopt this approach.

Role of choledochotomy after mechanical lithotripsy-related adverse event in endoscopic retrograde cholangiopancreatography.

In case of rupture of the mechanical lithotripter's traction wires during an ERCP, we suggest performing a choledochotomy to remove the stone, and remove the closed Dormia basket through the mouth.

Laparoscopic common bile duct exploration to treat choledocholithiasis in situs inversus patients: A technical review.

Situs inversus (SI) is a rare congenital condition characterized by a mirror-image transposition of the major visceral organs. Since the 1990s, more than one hundred SI patients have been reported to have successfully undergone laparoscopic cholecystectomy. In these cases, the major problem is to overcome is the left-right condition for right-handed surgeons. Laparoscopic common bile duct exploration (LCBDE), an alternative to treat patients with bile duct stones, has shown equivalent efficacy and is less likely to cause pancreatitis than endoscopic retrograde cholangiopancreatography. Recent updated meta-analyses revealed that a shorter postoperative hospital stay, fewer procedural interventions, cost-effectiveness, a higher stone clearance rate, and fewer perioperative complications are additional advantages of LCBDE. However, the technique is technically demanding, even for skilled laparoscopic surgeons. Conducting LCBDE in patients with difficult situations, such as SI, is more complex than usual. We herein review published SI patients with choledocholithiasis treated by LCBDE, including our own experience, and this paper focuses on the technical aspects.

Long-Term Outcomes of Laparoscopic Common Bile Duct Exploration Through Diathermy, Choledochotomy, and Primary Closure: A 6-Year Retrospective Cohort Study.

Background and Objective: Choledocholithiasis is a frequent pathology, unfortunately when its endoscopic management fails, there is no consensus of how it should be addressed. The aim of this study was to evaluate the safety, feasibility, and long-term outcomes of laparoscopic common bile duct exploration (LCBDE) using electrosurgery (coagulation) for choledochotomy followed by primary closure after endoscopic treatment failure. Materials and Methods: A retrospective cohort study of patients who underwent LCBDE from 2013 to 2018 was conducted in Bogotá, Colombia. Clinical demographics, operative outcomes, recurrence rate of common bile duct stones, and long-term bile duct complications were analyzed. A descriptive analysis was performed. Results: A total of 168 patients were analyzed. Most of the patients were males (53.37%) with a median age of 73 years with no comorbidities (65%). Stone clearance was successful in 167 patients (99.4%). Nonlethal complications were noted in 3 patients during the surgery or in the immediate postoperative (1.79%) and managed with T-tube or endoscopically. No cases of mortality surgery related were observed. There were no signs of any type of biliary injury or stricture observed in any of the patients during the 24-month follow-up period. Conclusions: LCBDE with diathermy and primary closure is a safe and effective treatment option for choledocholithiasis for failed endoscopic retrograde cholangiopancreatography in terms of long-term outcome as well as short-term outcome.

Learning Curve of Laparoscopic Common Bile Duct Exploration: A Systematic Review.

Background: Single-stage laparoscopic common bile duct exploration (LCBDE) with cholecystectomy has superior outcomes over two-stage endoscopic retrograde cholangiopancreatogram with interval cholecystectomy. With decreasing trend of LCBDE, this study aims to summarize the literature on learning curve (LC) in LCBDE. Materials and Methods: PubMed, Embase, Scopus, and the Cochrane Library were systematically searched for articles from inception to June 3, 2022 (PROSPERO Ref No: CRD42022328451). Basic clinical demographics were collected. Poisson means (95% confidence interval [95% CI]) was used to determine the number of cases required to surmount the LC (NLC). Results: Eight articles (n = 2071 patients) reported LC outcomes in LCBDE with mean study period of 5.9 ± 2.8 years. Majority of studies (62.5%) used arbitrary methods of LC analysis. Most common outcomes reported were complications (any or major) (75%), open conversion (75%), length of stay (62.5%), and operating time (50%). Mean CBD diameter was 11.3 ± 4.8 mm (n = 1122 patients). Incidence of acute cholecystitis, acute cholangitis, and acute pancreatitis were 13.9% (n = 232/1668), 7.8% (n = 128/1629), and 13.7% (n = 229/1668), respectively. Pooled analysis of all the included studies showed NLC of 78.8 cases (95% CI: 71.9-86.3). Studies that used cumulative sum control chart analysis, nonarbitrary methods, and arbitrary-based LC had NLC of 152.0 (95% CI: 135.4-170.1), 108.0 (95% CI: 96.6-120.4), and 49.7 (95% CI: 42.0-58.3) cases, respectively. NLC was 37.0 cases (95% CI: 29.1-46.5) for single surgeon LC, and 99.8 cases (95% CI: 90.2-110.0) for institutional LC. Conclusion: Studies reporting NLC in LCBDE are heterogeneous. Further studies should use nonarbitrary methods of analysis for patient-reported outcome measures and procedure-specific morbidity.

Clinical observation of laparoscopic cholecystectomy combined with endoscopic retrograde cholangiopancreatography or common bile duct lithotripsy.

BACKGROUND: The incidence of common bile duct (CBD) stones accounts for approximately 10%-15% of all CBD diseases. Approximately 8%-20% of these patients also have gallstones with heterogenous signs and symptoms. AIM: To investigate the clinical effects of laparoscopic cholecystectomy (LC) combined with endoscopic retrograde cholangiopancreatography (ERCP) and LC with CBD excision and stone extraction in one-stage suture (LBEPS) for the treatment of gallbladder and CBD stones. METHODS: Ninety-four patients with gallbladder and CBD stones were selected from our hospital from January 2018 to June 2021. They were randomly divided into study and control groups with 47 patients each. The study group underwent LC with ERCP, and the control group underwent LC with LBEPS. Surgery, recovery time of gastrointestinal function, complication rates, liver function indexes, and stress response indexes were measured pre- and postoperatively in both the groups. RESULTS: The durations of treatment and hospital stay were shorter in the study group than in the control group. There was no significant difference between the one-time stone removal rate between the study and control groups. The time to anal evacuation, resumption of oral feeding, time to bowel sound recovery, and time to defecation were shorter in the study group than in the control group. The preoperative serum direct bilirubin (DBIL), total bilirubin (TBIL), and alanine aminotransferase (ALT) levels were insignificantly higher in the study group than that in the control group. A day after surgery, the postoperative serum DBIL, TBIL, and ALT levels were lower than their preoperative levels in both groups, and of the two groups, the levels were lower in the study group. Although the preoperative serum adrenocorticotrophic (ACTH), cortisol (COR), epinephrine (A), and norepinephrine (NE) levels were higher in the study group than that in the control group, these differences were not significant (P > 0.05). The serum ACTH, COR, A, and NE levels in both groups decreased one day after surgery compared to the preoperative levels, but the inter-group difference was statistically insignificant. Similarly, (91.79 ± 10.44) ng/mL, A, and NE levels were lower in the study group than in the control group. The incidence of complications was lower in the study group than in the control group. CONCLUSION: LC combined with ERCP induces only a mild stress response; this procedure can decrease the risk of complications, improve liver function, and achieve and promote a faster recovery of gastrointestinal functions.

Laparoscopic choledochotomy and choledochoduodenostomy for the management of persistent common bile duct stones.

Choledochotomy and choledochoduodenostomy were commonly used technique in the early twentieth century to extract bile duct stones. Endoscopic retrograde cholangiopancreatography and sphincterotomy revolutionised the scenario and is currently the preferred first-line option for managing choledocholithiasis. However, in certain circumstances, where endoscopic retrograde cholangiopancreatography fails, choledochotomy and choledochoduodenostomy are the only available options. We present the case of an 86-year-old female with a background of multiple previous presentations with biliary sepsis and ascending cholangitis requiring multiple endoscopic retrograde cholangiopancreatographies that failed to remove all stones in the common bile duct. She underwent a laparoscopic choledochotomy and choledochoduodenostomy that successfully resolved her common bile duct obstruction. Laparoscopic choledochotomy and choledochoduodenostomy reduce the length of hospital stay and help to minimise complications associated with open surgery.

Surgical Treatment for Choledocholithiasis Following Repeated Failed Endoscopic Retrograde Cholangiopancreatography.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is the first line treatment for choledocholithiasis. In many occasions, several attempts of ERCP are performed until failure is declared and surgical treatment is applied, in many times following procedure-related complications. We present the results of surgical management of patients with choledocholithiasis following repeated failures of ERCP due to impaction of multiple large stones. METHODS: Patients that underwent surgical treatment for choledocholithiasis following repeated ERCP attempts between January 2006 and December 2018 were retrospectively assessed. Post-ERCP complications were evaluated and the surgical approach, technique, and outcomes were assessed. RESULTS: One hundred and two patients were operated on for choledocholithiasis following repeated failed ERCP. All the patients had at least 2 failed attempts (mean = 3.2 ± 1.7), and 25 (23.5%) suffered major ERCP-related complications. Following choledochotomy and stone extraction, bilioenteric anastomosis was done in the vast majority of patients (90.2%), most commonly choledochoduodenostomy (62%). Thirty-eight (37%) patients had minimally invasive procedure (laparoscopic n = 26, robotic assisted n = 12). Major post-operative complications (Clavien-Dindo ≥ 3) occurred in 24 patients (23.5%). Nine patients (8.8%) were re-operated and 10 (9.8%) were readmitted within 30 days from surgery. Three patients died within 30 days from surgery. Older patients had significantly more ERCP attempts and suffered higher post-operative mortality. During a median follow-up of 70 months, the only biliary complication was an anastomotic stricture in one patient. CONCLUSION: Surgery for CBDS after failure of ERCP is safe and provides a highly effective long-term solution.

Horseshoe kidney leading to ERCP failure; innovative use of guide wire during laparoscopic CBD exploration: A case report.

INTRODUCTION: Horseshoe kidneys are the most common fusion defect of the kidneys, which amounts to about 0.25% of the population. They are usually asymptomatic and are often identified incidentally. The horseshoe kidney can push the second and third part of the duodenum anteriorly, leading to an altered CBD course. Choledocholithiasis is seen in approximately 10-15% of patients with cholelithiasis. Presently, the most preferred approach for managing CBD stones is ERCP. However, in ERCP failure cases, Laparoscopic CBD exploration is the primary treatment modality, with or without T-tube use, with all the advantages of minimally invasive surgery. CASE PRESENTATION AND DISCUSSION: A 65-year-old female presented with complaints of pain in the right hypochondriac region for three months associated with nausea, jaundice, and loss of appetite and weight. Her USG abdomen showed cholelithiasis with dilated CBD with horseshoe kidney with severe hydronephrosis of the left kidney. They are usually asymptomatic and are often identified incidentally. In this patient, it was believed that the horseshoe kidney had pushed the second and third part of the duodenum anteriorly, leading to an altered CBD course leading to ERCP failure. MRCP confirmed cholelithiasis with choledocholithiasis with dilated CBD of 11.3 mm with horseshoe kidney. ERCP was attempted but was unsuccessful due to non-visualization of the papilla due to overcrowding of duodenal folds. For patients with ERCP failure, laparoscopic CBD exploration is mandatory. For this patient, the CBD was cannulated with a guidewire, if needed, for repeat ERCP and was closed with T-tube in situ. CONCLUSION: There are no particular preoperative indicators that can predict the failure of ERCP. However, in ERCP failure cases, laparoscopic CBD exploration (with or without T-tube use) is the primary treatment modality.

Dormia basket impacted during ERCP, resolved by laparoscopic bile duct approach: Case report.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice for treating and removing common bile duct (CBD) stones with high success rates. Among the adverse effects, impaction of the Dormia basket when removing the stones is an unusual complication. CASE PRESENTATION: Two cases of choledocholithiasis with endoscopic treatment by ERCP and Dormia basket impaction, resolved by a laparoscopic approach to the bile duct. DISCUSSION: Laparoscopic common bile duct exploration (LCBDE) has been developed as a technique to treat choledocholithiasis and simultaneously vesicular lithiasis by laparoscopy. LCBDE can be by means of a transcystic approach or by choledochotomy. The success of the treatment depends on surgical experience and the availability of adequate equipment, with high effectiveness to eliminate CBD stones and a success rate greater than 95%, it is equally effective for the resolution of adverse events during ERCP. CONCLUSION: LCBDE provides an alternative therapy where there is no other type of treatment for the resolution of complications of ERCP. It is a safe, effective and reliable technique with high success rates, which offers the benefits of a minimally invasive approach.

Transductal versus transcystic laparoscopic common bile duct exploration: an institutional review of over four hundred cases.

BACKGROUND: Many studies have failed to demonstrate significant differences between single- and two-staged approaches for the management of choledocholithiasis with concomitant gallstones in terms of post-operative morbidity. However, none of these studies paid specific attention to the differences between the methods of accessing the bile duct during laparoscopy. The aim of this study was to report outcomes of transcystic versus transductal laparoscopic common bile duct exploration (LCBDE) from our experience of over four hundred cases. METHODS: Retrospective review of 416 consecutive patients who underwent LCBDE at a single-centre between 1998 and 2018 was performed. Data collected included pre-operative demographic information, medical co-morbidity, pre-operative investigations, intra-operative findings (including negative choledochoscopy rates, use of holmium laser lithotripsy and operative time) and post-operative outcomes. RESULTS: Transductal LCBDE via choledochotomy was achieved in 242 patients (58.2%), whereas 174 patients (41.8%) underwent transcystic LCBDE. Stone clearance rates, conversion to open surgery and mortality were similar between the two groups. Overall morbidity as well as minor and major post-operative complications were significantly higher in the transductal group. The main surgery-related complications were bile leak (5.8% vs 1.1%, p = 0.0181) and pancreatitis (7.4% vs 0.6%, p = 0.0005). Median length of post-operative stay was also significantly greater in the transductal group. CONCLUSION: This study represents the largest single study to date comparing outcomes from transcystic and transductal LCBDE. Where possibly, the transcystic route should be used for LCBDE and this approach can be augmented with various techniques to increase successful stone clearance and reduce the need for choledochotomy.

Application of needle-type choledochotomy in laparoscopic common bile duct exploration / 国际外科学杂志

Objective:To introduce the usefulness and advantages of needle-type choledochotomy in laparoscopic common bile duct exploration.Methods:A retrospective analysis for the data of 1 107 patients who successfully implemented laparoscopic common bile duct exploration in Subei People′s Hospital of Jiangsu Province from January 1, 2013 to December 31, 2020 were applied. All cases were divided into the study group 662 cases with needle-type choledochotomy) and the control group (445 cases with non-needle-type choledochotomy) according to the manipulation of common bile duct incision. The time-cost, incidences of bleeding and bile leakage, as well as the recurrence rate of bile duct stone and the incidence of bile duct stenosis were observed and compared between the two groups. Normally distributed data were expressed as mean±standard deviation ( Mean± SD) and compared by t test while count data were expressed as frequency or percentage and compared by chi-square test or Fisher′s exact test. Results:The bile duct incision time and bleeding rate were (14.45±2.46) s and 25.1% in the study group, (104.48±15.32) s and 68.1% in the control group, respectively. The differences between the two groups were statistically significant ( P<0.001). The incidence of stone recurrence, biliary leakage, and bile duct stricture were 3.0%, 3.6% and 0.3% in the study group, 4.9%, 5.6% and 0.4% in the control group, respectively. There were no statistically significant differences between the two groups ( P>0.05). Conclusion:Needle-type bile duct incision can be used as a routine manipulation in laparoscopic common bile duct exploration for its time-saving, less bleeding, safe and easy to handling.

Impact of choledochotomy techniques during laparoscopic CBD exploration on short- and long-term clinical outcomes: Time to change concepts (a retrospective cohort study).

BACKGROUND: complications after laparoscopic common bile duct exploration (LCBDE) regarding choledochotomy techniques have not been adequately studied in the literature. Therefore, this study aimed to retrospectively analyze and compare the impact of choledochotomy techniques during LCBDE among patients with choledocholithiasis during the early and late postoperative periods. METHODS: From March 2014 to February 2018, 85 patients with choledocholithiasis (52 females and 33 males) were enrolled in this study. These patients were treated by LCBDE using various choledochotomy techniques, including scalpel or scissor (28 patients, 33%) in group I, diathermy hook (35 patients, 41%) in group II, or an ultrasonic device (22 patients, 26%) in group III. Postoperative follow-up was done for assessment of all possible complications, either early (within the first six months postoperatively) or late (2-6 years postoperatively), with meticulous observation and study of any relevant postoperative events. RESULTS: No statistical difference was detected among the three groups regarding the short- and long-term clinical outcomes, including biliary fistula, biliary stricture, cholangitis, recurrent stones, peritoneal sepsis, wound sepsis, or wound dehiscence. CONCLUSION: The long-lasting concepts of avoidance of using energy machines such as diathermy and ultrasonic devices with biliary structures should be changed. However, a statistical type I error cannot be excluded because of the small sample size. Therefore, further analysis of prospective randomized studies with a larger number of participants is strongly recommended.

Laparoscopic common bile duct exploration with primary closure is safe for management of choledocholithiasis in elderly patients.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) is one of the minimally invasive options for choledocholithiasis. Primary closure of the common bile duct (CBD) upon completion of laparoscopic choledochotomy is safe in selected patients. The present study aimed to evaluate the feasibility and safety of primary closure of CBD after LCBDE in patients aged 70 years or older. METHODS: A total of 116 patients (51 males and 65 females) who suffered from choledocholithiasis and underwent primary closure of the CBD (without T-tube drainage) after LCBDE from January 2003 to December 2017 were recruited. They were classified into two groups according to age: group A (≥70 years, n = 56), and group B (<70 years, n = 60). The preoperative characteristics, intraoperative details, and postoperative outcomes of the two groups were evaluated. RESULTS: The mean operative time was 172.02 min for group A and 169.92 min for group B (P = 0.853). The mean hospital stay was 7.40 days for group A and 5.38 days for group B (P < 0.001). Bile leakage occurred in two patients in group A and one in group B (3.57% vs 1.67%, P = 0.952). There were no significant differences in the rates of postoperative complications and mortality between the two groups. At median follow-up time of 60 months, stone recurrence was detected in one patient in group A and two in group B (1.79% vs 3.33%, P = 1.000). Stenosis of CBD was not observed in group A and slight stenosis in one patient in group B (0 vs 1.67%, P = 1.000). CONCLUSION: Primary closure of the CBD upon completion of laparoscopic choledochotomy is safe and feasible in elderly patients ≥70 years old.

T-tube-free single-incision laparoscopic common bile duct exploration plus cholecystectomy: a single centre experience.

BACKGROUND: The present study aimed to explore the indications and feasibility of T-tube-free trans-umbilical single-incision laparoscopic common bile duct exploration (SILCBDE) plus laparoscopic cholecystectomy (LC) for treating choledocholithiasis. METHODS: Patients hospitalized in the Second Affiliated Hospital (Shengjing Hospital) of China Medical University from January 2010 to January 2017 with the diagnosis of common bile duct stones and treated with T-tube-free trans-umbilical single-incision LC plus common bile duct exploration were retrospectively analysed. RESULTS: A total of 37 male/female choledocholithiasis patients (mean age 65 years, range 29-86) were treated with T-tube-free trans-umbilical SILCBDE plus LC. No intraoperative complication or conversion to open surgery occurred in any of the cases. The mean operative time was 99.8 min (range 84-125) for endoscopic nasobiliary drainage group (n = 6), 113.8 min (range 70-150) for endoscopic retrogradebiliary drainage group (n = 2), 131.1 min (range 75-161) for pigtail J-tube group (n = 24), 113.7 min (range 100-150) for primary closure group (n = 5). The mean post-operative hospital stay length was 5.5 days (range 4-7) for endoscopic nasobiliary drainage group, 12.5 days (range 10-15) for endoscopic retrogradebiliary drainage group, 6.5 days (range 4-10) for J-tube group, 5.8 days (range 4-9) for primary closure group. Pancreatitis, bile leakage and peritonitis were not presented in any of the group. After 17-101 months follow-up, three patients presented recurrent common bile duct stones. CONCLUSION: In selected cases, T-tube-free trans-umbilical SILCBDE plus LC is feasible and safe for experienced surgeons, and can achieve similar therapeutic effects as common LC plus common bile duct exploration procedures.