Purpose: A prospective work to study various laparoscopic techniques used for stone extraction during laparoscopic common bile duct exploration (LCBDE), either through the scope method using basket and balloon with Choledochoscopic control, direct access extraction of stones using basket, balloon, or reticulated graspers with CBD milking, or irrigation / suction techniques.  Assessment of CBD clearance of stones for each maneuver will be conducted with discussion of its feasibility, and difficulties encountered to evaluate its role in laparoscopic procedure.

Patients & Methods:  A random sample of cases of chronic calcular cholecystitis, with CBD stone(s) were enrolled in the study, and treated by laparoscopic cholecystectomy plus choledocholithotomy. Various methods were used for stone extraction either through the scope techniques, direct access techniques, or irrigation / suction technique. Assurance of CBD clearance of stones was done later using intra-operative choledochoscopy, cholangiogram, or post operatively using sonography, or MRCP.  

Results: Fifty patients were enrolled in this study (29 females and 21 males), laparoscopic basket and/or balloon CBD stone extraction was done through scope control in 25 patients, direct access  basket, balloon, or grasper techniques was done in 15 patients, while irrigation / suction techniques was done in 10 cases

Through choledochoscope basket or balloon method was effective in distal CBD stones of average size (0.5-1.0 cm), and number (1-5), but unfortunately missed stone is a relative risk (4%). Direct access basket, balloon, or reticulated grasper techniques is as effective blindly especially if associated with irrigation / suction techniques in non-impacted single distal stone of average size (0.5-1.0 cm) well recognized by MRCP night before operation with relatively low if non risk of missed stones. On the other hand, cholangiogram guided direct access basket and/or balloon extraction techniques was the techniques of choice for all stones sizes, numbers, either impacted or non, distal or proximal with marvelous results.

All techniques require high skills experienced team, up-to-date equipment's, and good selection of patients. The association between LCBDE and intra-operative cholangiogram has high CBD clearance rate which was not achieved by choledochoscope approaches. Experience influence treatment and it is mandatory with other facility and equipment for management of such cases.

Conclusion: LCBDE approach was feasible, with some difficulties especially in non-dilated duct, requires experienced team to be implemented. It is advised to carryon its role on a greater scale of cases to gain a consensus.