Laparoscopic Treatment for Unsuspected Common Bile Duct Stones by Transcystic Sphincter of Oddi Pneumatic Balloon Dilation and Pressure-Washing Technique Luigi Masoni • Francesco Saverio Mari • Vincenzo Pietropaolo • Maurizio Onorato • Massimo Meucci • Antonio Brescia Ó Socie ´te ´ Internationale de Chirurgie 2013 Abstract Background Unsuspected common bile duct stones (CBDS) are found in 4–5 % of patients with cholelithiasis. The optimal strategy for the treatment of asymptomatic CBDS, diagnosed during laparoscopic cholecystectomy (LC), is not yet well established. A one-stage solution is preferable to solve the CBDS during the LC and to avoid the exposure of patients to the risks of a second procedure, such as complications or failure. Methods We attempted to remove CBDS by transcystic sphincter of Oddi pneumatic balloon dilation and common bile duct pressure-washing in all cases of intraoperative identification of CBDS since September 2008. Results In 29 cases, unsuspected CBDS was identified by intraoperative cholangiography; in 28 cases a single stone with a mean diameter of 4.3 mm (range = 3–6) was detected and in one case three 5–8-mm-diameter stones were identified. Clearance of the common bile duct was obtained in 27 cases (96 %), with a mean operative time of 54 min (range = 36–90) and mean length of hospital stay of 2.5 days. Conclusion Treatment of unsuspected CBDS detected by intraoperative cholangiography during LC with this origi- nal technique was safe and effective and a viable alterna- tive of the transcystic endoscopic approach. Introduction The incidence of unsuspected common bile duct stones (CBDS) in patients with cholelithiasis is 4–5 %, whereas the incidence of CBDS is 5–10 % [1, 2]. Today, the opti- mal strategy for the treatment of asymptomatic CBDS, diagnosed during laparoscopic cholecystectomy (LC), is not yet well established. In recent years, several methods have been proposed for the treatment of asymptomatic CBDS. The most popular is endoscopic retrograde chol- angiopancreatography (ERCP) with endoscopic sphincter- otomy or with sphincter of Oddi pneumatic dilation performed during the same procedure (rendezvous) or afterward (two-stage) [3]. It is obvious that a delay in CBDS clearance may expose the patient to the risks of a second procedure (such as complications or failure), and, therefore, a one-stage solution is typically advisable. Another very common technique is laparoscopic common bile duct (CBD) exploration with a choledochoscope inserted via the cystic duct or directly through a choledo- chotomy. Conversion to open surgery after positive intra- operative cholangiography (IOC) is also possible. Some authors have also proposed clinical observation with or without medical therapy. Obvious difficulties in organizing an unplanned ERCP when CBDS are identified during elective LC led us to develop an original method to obtain clearance of the CBD during the same laparoscopic intervention. L. Masoni Á F. S. Mari (&) Á M. Meucci Á A. Brescia Department of Medical and Surgical Sciences and Translational Medicine, School of Medicine and Psychology, University Sapienza of Rome, Rome, Italy e-mail: frasavmari@yahoo.it V. Pietropaolo Á M. Onorato Department of Gastroenterology and Endoscopy, School of Medicine and Dentistry, University Sapienza of Rome, Rome, Italy 123 World J Surg DOI 10.1007/s00268-013-1992-y