الفهرس 
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Abstract
This study was carried out on thirty patients with gallstones and small secondary common bile duct stones less than 10 millimeters in diameter. The aim of this study was to evaluate the role and feasibility of laparoscopic common bile duct exploration through the cystic duct for clearance of these small stones.
There were twenty females (66.7 %) and ten males (33.3 %), their age ranged from 25– 64 years with a mean age of 43.80 ± 11.42 years. All cases were subjected to thorough history taking and complete clinical examination. Laboratory investigations (aspartate aminotransferase, alanine aminotransferase, total and direct bilirubin, alkaline phosphatase and gamma-glutamyl transferase) followed by ultrasonography, computed tomography (CT) of the abdomen or magnetic resonance cholangiopancreatography (MRCP).
Patients with gallstones and small secondary CBD stones less than 10 mm as confirmed by ultrasonography and/or MRCP were included in this study. Patients with large stones, suspicion of other biliary pathology, extremes of age or unfitness for laparoscopic surgery were excluded.
Patients were subjected to intraoperative cholangiography (IOC); 17 cases (56.6%) had a single CBD stone, 8 cases (26.6%) had two CBD stones, 5 cases (16.6%) had 3 CBD stones.
Different transcystic techniques were employed to clear the CBD of stones. These techniques included saline irrigation, fluoroscopiuc wire basket stone retrieval, choledochoscopic basket stone extraction. If these methods failed, (Rendez-vous technique or intraoperative ERCP) was tried. After failure of all laparoscopic approaches, open CBD exploration was the last choice. IOC and/or choledochoscopy were the endpoint for assessment of complete CBD clearance of stones.
The transcystic approachs was successful in 22 cases (73.3%), the Rendez-vous technique succeeded in further 5 cases (16.6%), 3 cases (10%) were converted to open surgical treatment.
Saline irrigation or stone pushing with a tube catheter was tried in all cases and was successful in 12 cases (40%) in flushing stone(s) out of the CBD to the duodenum, fluoroscopic wire basket stone retrieval in 14 cases (46.6%) with a success rate of 42.8%, choledochoscopic basket stone extraction in 7 cases (23.3%) with a success rate of 57.1%.
The mean duration for all techniques from insertion of Veress needle till the end of procedure was 120.5 ± 21.87 minutes (range 90 – 170 minutes).
The mean hospital stay was 4.1 ± 3.63 days (range from 1 to 20 days), In successful transcystic cases (n = 22), the mean postoperative hospital stay from the day of surgery till discharge was 2.8 days ± 1.24 (range from 1 to 6 days), while in failed cases it was much longer 6 ± 5 days (range 1 to 20 days).
Peristalsis was audible and oral fluid intake started in the same day of surgery in 12 cases (40%), oral fluid intake commenced on the first postoperative day in 11 patients (36.7%). Oral fluid intake was delayed to postoperative day two in 5 patients (16.7%) and to postoperative day three in the two cases (6.6%).
Complications that occurred, 1 patient had a dissecting biliary injury (3.3%), 2 cases (6.7%) of retained stones, In 2 cases (6.7%) mild bile leak was detected, 8 patients, (26.7%) developed postoperative chest complications, 5 cases (16.7%) developed postoperative pancreatitis, 5 cases (16.7%) had trocar site infection.