Challenging the Dogmas: Laparoscopic Common Bile Duct Exploration through Diathermy, Choledochotomy and Primary Closure. Long-term Outcomes in a Referral Center

Introduction
Choledocholithiasis is a frequent pathology, unfortunately when its endoscopic management fails there is no consensus on 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 (LCDBE) using electrosurgery (coagulation) for choledochotomy followed by primary closure after endoscopic treatment failure.

Methods
A retrospective cohort of 168 patients who underwent LCDBE from 2013 to 2018 which was conducted all by choledochotomy. Clinical demographics, operative outcomes, recurrence rate of CBD stones, and long-term bile duct complications were analyzed.

Results
The male/female ratio was 90/78 and mean age was 73 years. 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 surgery-related mortality 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 through choledochotomy with diathermy and primary closure can be performed without increased risk of operative complications such as important and visual-impairment bleeding as well as long-term complications such as bile duct stricture or recurrent CBD stones. LCBDE with diathermy and primary closure is a safe and effective treatment option for choledocholithiasis for failed ERCP in terms of long-term outcome as well as short-term outcome.