**8. Analysis of the results**

In an effort to find out the best option for treatment of patients with high medical risk (e.g., AOC), a randomized, clinical trial was published comparing the outcomes of preoperative ERCP and subsequent laparoscopic cholecystectomy (LC)–as a two-stage procedure versus LCBDE + LC (as a one-stage intervention). The authors concluded that even though there was no difference between approaches regarding duct clearance, postoperative stay, early complications, or conversion in higher-risk patients, the LCBDE was more effective and efficient and avoided unnecessary procedures [62].

In a systematic review and network meta-analysis, the authors compare the efficacy and safety of four surgical approaches to CBD stones retrieval: preoperative ERCP and subsequent LC (two-stage procedure), LC + intraoperative ERCP (onestage procedure), LC + postoperative ERCP (two-stage procedure), and LCBDE + LC (as a one-stage intervention). As a result, the authors draw the following conclusions: All approaches had similar results regarding overall mortality. LC plus LCBDE was the most successful for avoiding overall bleeding, for the shortest operative time and total cost. LC + intraERCP was the best approach for the length of hospital stay.

In general, LC + intraERCP approach is the safest and the most successful technique. LC + LBCDE appears to reduce the risk of acute pancreatitis but may be associated with a higher risk of biliary leak and biliary peritonitis [63].

According to the meta-analysis comprising 4224 patients, the authors compare the results after laparoscopic transcystic exploration (LTCE) of CBD and laparoscopic transductal exploration, by choledochotomy (LTDE) for extraction of CBD stones. They found out that a successful duct clearance occurred more often with LTDE than with LTCE. The analysis revealed no significant differences in the conversion to open procedures, total morbidity, operating time, or blood loss. Even though the LTDE has a longer duration of surgery and the patients have a longer hospital stay. There was also no significant difference in the postoperative bile duct stricture or reoperation observed. The higher risk of bile leak and early peritonitis after LTDE is the most frequent complication, which can be explained by the fact that bile duct suturing is a challenging task and has a significant learning curve [64]. According to the literature, the operation time of LCBDE decreases as the experience of the surgeon increases [50].

Another meta-analysis, comparing the results obtained from LTCE and LTDE approach, make the conclusion that LTCE access is safer and has lesser biliary complications [58].

Extraction of the CBD stones by transductal approach is the easier way, compared to the transcystic technique. At the same time, the risk of complications after choledochotomy is more important than the risk after the transcystic approach. That is why many authors prefer the transcystic technique in clinical practice [65, 66].

We perform choledochotomy by laparotomy and leave a T-tube in the CBD for more than 100 years. The reason for that is to decompress the CBD during the postoperative period and to check for retained stones by cholangiography [67]. Today many authors associate the placement of T-tube with complications after LCD [68].

Two meta-analyses published in 2020 and in 2021, with 1865 and 604 patients enrolled compare the results of primary duct closure (PDC) versus T-tube drainage (TTD) after LCBDE. Statistically, there were no significant differences in the early postoperative complication as bile leakage, retained stones or postoperative time between the TTD and PDC groups. According to this article, PDC is safe and effective and can be used as the first choice after transductal LCBDE in patients with cholelithiasis. The authors revealed significantly less hospital expenses calculated in the PDC group compared with the TTD group. Even the long-term complications after PDC, such as CBD stricture or retained stones, are shown to be insignificant [46, 69–71].

Today ERCP is the first-line treatment for choledocholithiasis with an overall procedural success–85.8%, according to the nationwide quality registry in the Netherlands. A study published in 2021, comparing the effect of treatment after LCBDE (as a first-line intervention) and LCBDE (after failed ERCP). In this metaanalysis, including 642 patients, the conclusion was that overall complications, bile leakage, conversion, and postoperative hospital stay were comparable in both groups. *Laparoscopic Approach in the Case of Biliary Obstruction: Choledocholithiasis DOI: http://dx.doi.org/10.5772/intechopen.106042*

The overall procedural success of LCBDE, after failed ERCP, was more than 90%. The author notes that LCBDE is an alternative acceptable procedure when endoscopic therapy fails [72, 73].

Usually, the operation time of LCBDE range from 90 min. to 240 minutes according to the literature. The estimated blood loss during the operation was less than 200 mL, and no blood transfusion was required during any operation.

The percentage of conversion to laparotomy was negligible [70–72].

In all patients with choledochotomy and T-tube left in the CBD, the surgeon usually also place a drainage tube at the Winslow hole.
