Journal Review in Minimally Invasive Surgery: Common Bile Duct Exploration

Behind The Knife: The Surgery Podcast

Science, Health & Fitness, Medicine, Education

4.8 • 1.4K Ratings

🗓️ 8 December 2025

⏱️ 25 minutes

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Summary

In this episode of Behind the Knife, the minimally invasive surgery (MIS) team dives deep into the evolving field of common bile duct exploration (CBDE). From the historical context of laparoscopic approaches to the latest advances including robotic-assisted techniques, Drs. Shaina Eckhouse, James Jung, Zachary Weitzner, and Joey Lew discuss key evidence shaping modern practice. Listeners will learn about indications and anatomy guiding trans-cystic versus trans-choledochal approaches, practical tips for safe stone clearance, and critical considerations around learning curves and team coordination for robotic procedures. The episode also highlights important studies comparing single-stage laparoscopic CBDE with staged ERCP and cholecystectomy, emphasizing outcomes such as stone clearance, pancreatitis rates, and hospital length of stay. This comprehensive overview is a must-listen for MIS and acute care surgeons interested in optimizing the management of choledocholithiasis and streamlining patient care with minimally invasive techniques.

Hosts:
- Shaina Eckhouse, MD, Bariatric Surgery Medical Director and Vice Chair of Clinical Operations, Department of Surgery, Duke University
- James Jung, MD, PhD, Assistant Professor of Surgery, Duke University
- Zachary Weitzner, MD, Minimally Invasive and Bariatric Surgery Fellow, Duke University, @ZachWeitznerMD
- Joey Lew, MD, MFA, Surgical resident PGY-3, Duke University, @lew__actually

Learning Goals:
By the end of this episode, listeners will be able to:
- Describe the historical approaches to managing choledocholithiasis, including staged interventions and the evolution toward single-stage laparoscopic common bile duct exploration (CBDE).
- Summarize key clinical evidence comparing CBDE and ERCP, including landmark studies and meta-analyses evaluating outcomes, complications, and trends over time.
- Distinguish between transcystic and transcholedochal approaches to CBDE, explaining indications, contraindications, and technical nuances for each technique.
- Identify appropriate candidates for transcystic exploration based on cystic duct anatomy and stone characteristics.
- Recognize the impact of newer surgical technologies—such as digital choledochoscopy, Spyglass, and robotic platforms—on CBDE practice, efficiency, and safety.
- Discuss the importance of multidisciplinary teamwork, preparation, and perioperative planning for successful CBDE, particularly in complex or altered anatomy cases.
- Appraise the learning curve and quality of evidence for new CBDE procedures, outlining the need for mentorship, ongoing training, and knowing when to collaborate with GI or hepatopancreaticobiliary (HPB) surgery.
- Outline approaches and bailout strategies for challenging cases, including patients with surgically altered anatomy and use of adjuncts such as intraoperative cholangiography (IOC), feeding tube placement, and Fanelli stents.
- Evaluate safety outcomes and limitations associated with robotic-assisted CBDE and single-stage management, incorporating recent data from population-based studies.
- Reflect on strategies for tailoring CBDE techniques to individual patient anatomy, surgeon experience, and available resources, advocating for evidence-based practice and continuous learning.

References:
- Giurgiu DI, Margulies DR, Carroll BJ, et al. Laparoscopic Common Bile Duct Exploration: Long-term Outcome. Arch Surg. 1999;134(8):839-844. doi:10.1001/archsurg.134.8.839 https://pubmed.ncbi.nlm.nih.gov/10443806/
- Lyu Y, Cheng Y, Li T, Cheng B, Jin X. Laparoscopic common bile duct exploration plus cholecystectomy versus endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for cholecystocholedocholithiasis: a meta-analysis. Surg Endosc. 2019;33(10):3275-3286. doi:10.1007/s00464-018-06613-w https://pubmed.ncbi.nlm.nih.gov/30511313/
- Bekheit M, Smith R, Ramsay G, Soggiu F, Ghazanfar M, Ahmed I. Meta‐analysis of laparoscopic transcystic versus transcholedochal common bile duct exploration for choledocholithiasis. BJS Open. 2019;3(3):242-251. doi:10.1002/bjs5.50132 https://pubmed.ncbi.nlm.nih.gov/31183439/
- Cironi K, Martin MJ. Reclaim the duct! Laparoscopic common bile duct exploration for the acute care surgeon. Trauma Surg Acute Care Open. 2025;10(Suppl 1). doi:10.1136/tsaco-2025-001821 https://pubmed.ncbi.nlm.nih.gov/40255986/
- Zhang C, Cheung DC, Johnson E, et al. Robotic Common Bile Duct Exploration for Choledocholithiasis. JSLS J Soc Laparosc Robot Surg. 2025;29(1):e2024.00075. doi:10.4293/JSLS.2024.00075 https://pubmed.ncbi.nlm.nih.gov/40144383/
- Kalata S, Thumma JR, Norton EC, Dimick JB, Sheetz KH. Comparative Safety of Robotic-Assisted vs Laparoscopic Cholecystectomy. JAMA Surg. 2023;158(12):1303-1310. doi:10.1001/jamasurg.2023.4389 https://pubmed.ncbi.nlm.nih.gov/37728932/

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Transcript

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0:00.0	Behind the Knife, The Surgery Podcast, relevant and engaging content designed to help you
0:11.6	dominate the day.
0:27.0	Welcome back to Behind the Knife, the Surgery podcast where we bring you the cutting edge of surgical science and technique.
0:40.3	In this episode, our MIS team will take on common biodect explorations, reviewing key papers that have shaped our approach to Koloidosiasis from our first four ways in laparoscopic exploration to new and bona fide robotic options. I'm Shayna Eckhouse, Associate Professor of Surgery, Medical Director
0:45.2	at Baratricet Surgery, and Vice Chair of Clinical Operations for the Department of Surgery here at Duke.
0:49.0	And I'm joined today with Dr. James Jung, Assistant Professor of Surgery, Dr. Zachary Whitesner,
0:53.7	our minimally invasive and bariatric surgery fellow, and Dr. Joey Lev, one of our surgical residents. Joey, get us started. Awesome. Let's dive right in. Historically, the purview of both endoscopists and surgeons, collidogical athiasis has increasingly been tackled in single-stage interventions. We do the colostectomy, we get rid of the duck stones, and we obviate
1:11.1	the need for another intervention. When unsuccessful, ERCP remains an option, but how do we get here?
1:16.0	In 1999, a prospective cohort study came out in JAMA surgery called laparoscopic common bile duct
1:20.8	exploration long-term outcome. Patients with colidocytosis that underwent lap common bioduct
1:25.8	exploration, or lap CBDE, were followed with surveys over an average of five years on pain, retained stones and other symptoms.
1:33.1	The rate of failure was exceedingly low, 3%, and retained stones were found in just one patient of the 116 that returned the surveys, but it's still taken time to come into vogue.
1:42.3	When I started practicing, we already knew that lap CBDE was effective, but the norm was still to do the Coley first and ERCP second.
1:49.1	It was the exception, not the rule, to do it this way.
1:51.1	In fact, my practice pattern since becoming and attending, has been to not do IOC because I don't enjoy doing it with time that has changed because of my primary specialty
2:01.7	in metabolic and bariatric surgery, where we have to consider IOC in every patient with
2:06.6	surgically altered anatomy.
2:08.6	Yeah, Shida, I think you and I are contemporary in when we trained.
2:14.6	And during the time, I don't think lab CBD exploration was that common
2:20.3	or commonly taught. I think the usual practice had been, you know, if there's high
2:27.8	preoperative suspicions for CBD stone, then it would be ERCP first and then perform
2:34.1	laparoscopic colicisisysectomy.
	...

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