1. Exploration of the Common BileDuct:The Laparoscopic Approach

2. Contraindications General • ■ High risk patients (ASA III or IV) for whom an endoscopic approach is preferred • ■ Dense peritoneal adhesions due to previous upper abdominal surgery (a limitation • for the laparoscopic approach) • ■ Liver cirrhosis with portal hypertension/severe coagulation disorders • Transcystic • ■ Presence of obstructive cystic valves (associated with a risk of instrumental CD • or CBD injury) • ■ Stones too large for TC stone extraction • ■ Stones located in the common hepatic duct or in intrahepatic bile ducts • ■ Inadequate biliary anatomy of the CD (tortuous, etc.) and the CD–CBD junction • (parapapillary insertion, acute angle of insertion of CD into CBD, etc.) • Choledochotomy • ■ Thin CBD (risk of stricture after suturing) • ■ The presence of severe inflammation (gangrenous cholecystitis, acute necrotizing • pancreatitis, etc.) at the porta hepatis, precluding a safe identification of CBD

3. Preoperative Investigations • History and evaluation: Previous and actual clinical history of biliary symptoms • Pain, jaundice, fever, chills, signs of pancreatitis • Laboratory tests: White blood cell (WBC) count, CRP, bilirubin,ALT,AST, alkaline • phosphatase, amylase, lipase, coagulation parameters • Preoperative radiologic Ultrasound, MR cholangiography, endoscopic ultraassessment: • sonography • Conditions for LCBDE • ■ Adequate experience in open biliary surgery and in laparoscopic advanced procedures, • in suturing techniques and in endoscopic techniques • ■ Routine practice of Intraoperative cholangiography (IOC) • ■ Adequate technical environment (instrumentation, fluoroscopy, flexible scopes, etc.)

4. Instrumentation/Material • LCBDE is a technically demanding operation requiring: • ■ High volume insufflator • ■ High energy light source • ■ Fluoroscopic intraoperative cholangiographic equipment • ■ Dormia basket or balloon extraction baskets • ■ Flexible endoscope 3.5mm (fine, fragile and expansive) • ■ Contact or laser lithotripsy device (optional) • ■ Laparoscopic knife • ■ Laparoscopic needle holder • ■ Transcystic drain or T-tube