**2.2 Endoscopic sphincterotomy prior to laparoscopic cholecystectomy**

Common bile duct stones are found in 10% of patients undergoing elective cholecystectomy [11]. In these patients, management of common bile duct stones includes endoscopic sphincterotomy (ES) prior to or after laparoscopic cholecystectomy (LC) or LC with intraoperative common bile duct exploration. Many studies evaluated both approaches with controversial outcomes. A meta-analysis of 12 studies did not find any difference in mortality, morbidity or in the need for an additional procedure between both approaches [12]. However, a decision analysis published in 2008 suggested that LC with intraoperative bile duct exploration is superior to ES with LC [13]. Most likely, these controversial results could be explained by the difference in expertise among surgeons in performing laparoscopic common bile duct exploration. Recently, Intraoperative Endoscopic sphicnterotomy by Endoscopic Retrograde Cholangiopancreatography (ERCP) during LC was introduced as an alternative technique for the management of Choledocholithiasis. Enochsson et al. evaluated this technique in 37 patients with a 93.5% success rate and none of the patients developed post ERCP pancreatitis [14]. Intraoperative ERCP was compared to preoperative ERCP in patients with choledocholithiasis in a study by ElGeidie et al. The study included 198 patients and it did not find any difference in the morbidity or in the procedure time between the two approaches [15]. However, Intraoperative ERCP during LC has the advantage of being able to perform the procedure and surgery in a single stage procedure, making it an attractive option.
