Laparoscopic Bile Duct Clearance Without Choledochoscopy Ahmed ElGeidie, MD, Ehab Atif, MD, MRCS En, Yussef Naeem, MD, and Gamal ElEbidy, MD Background: Laparoscopic common bile duct exploration (LCBDE) has been proven to be a safe, efficient, and cost-effective option for the management of common bile duct (CBD) stones. There are two guiding methods during LCBDE: fluoroscopic or choledochoscopic. Most surgeons prefer the use of flexible chol- edochoscopy at LCBDE, but it is a fragile, delicate, and expensive instrument. The aim of this work was to report our experience in fluoroscopically guided LCBDE. Patients and Methods: A retrospective review of all patients who underwent LCBDE in the Mansoura Gastroenterology surgical center between March 2007 and September 2014 was performed. Patients with gallstones and concomitant CBD stones were included. After the initial assessment, all patients fulfilling the criteria of enrollment underwent magnetic resonance chol- angiopancreatography, and only patients with magnetic resonance cholangiopancreatography or endoscopic retrograde chol- angiopancreatography evidence of CBD stones were included. Choledochoscopy was not used in any patient, and we depended on fluoroscopic guidance for CBD stone retrieval in all LCBDE. Results: A total of 290 patients were assessed for LCBDE: 76 patients were excluded; 11 patients were not completed lapa- roscopically due to negative intraoperative cholangiography (n = 7) and conversion to laparotomy (n = 4); the remaining 203 patients were analyzed. LCBDE failed in 16 of the 203 (7.9%) cases, with a success rate of 92.1%. The median operative time was 79 minutes, and the median hospital stay was 2.4 days. Compli- cations were bile leakage (n = 4), mild pancreatitis (n = 2), wound infection (n = 2), port hernia (n = 1), and internal hemorrhage (n = 1). Conclusions: Compared with published studies using choledocho- scopy at LCBDE, we found comparable results in terms of the success/failure rate, the morbidity and mortality, the operative time, and the length of hospital stay. LCBDE under fluoroscopic guidance may be as safe and efficient as with choledochoscopic guidance. Key Words: CBD, common bile duct stones, choledocoscope, lap- aroscopic CBD, exploration, ERCP, choledochlithiasis, laparo- scopic common bile, duct exploration, choledochoscopy (Surg Laparosc Endosc Percutan Tech 2015;25:e152–e155) A pproximately 5% to 15% of the patients with gallbladder stones have common bile duct (CBD) stones, and there is a general agreement that CBD stones must be treated to avoid complications. 1–4 Open surgery for the removal of both gall- bladder and CBD stones was the standard therapy for these patients. It was found to be associated with the lowest incidence of retained stones, 3 but it has a high morbidity and mortality, particularly in elderly patients. 5 Two revolutions occurred in last few decades that changed the way of management of cholecystocholedocholithiasis. These were laparoscopic cholecystectomy (LC) and endoscopic retrograde cholangiopancreatography (ERCP). Currently, the minimally invasive approach is preferable to the old open option. The minimally invasive approach may be either sequential (pre- operative ERCP followed by LC or LC followed by post- operative ERCP) or single session [laparoscopic common bile duct exploration (LCBDE) or intraoperative ERCP]. 6–10 LCBDE is preferred by many authors as a single-stage minimally invasive option to avoid endoscopic sphincter- otomy and its sequalae. LCBDE was found to be efficient, safe, cost effective, and well-accepted by patients because the 2 different pathologic conditions are solved in a single surgical procedure. 4,11–15 At LCBDE, CBD stones could be removed either under fluoroscopic guidance or using chol- edochoscopy. The most commonly used guiding method all over the world is flexible choledochoscopy. However, it is a delicate, fragile, and expensive instrument that may not be available all the time. The aim of this work was to report our institution’s experience in fluoroscopically guided LCBDE using a flexible choledochoscope. PATIENTS AND METHODS Study Population A retrospective review of all patients who underwent LCBDE in the Gastroenterology surgical center, Mansoura University, Egypt, between March 2007 and September 2014 was performed. Patients with gallstones and concomitant CBD stones as diagnosed by clinical presentation, blood tests, and abdominal ultrasound were included. After the initial assessment, all patients fulfilling the criteria of enrollment underwent magnetic resonance cholangio- pancreatography, and only patients with magnetic resonance cholangiopancreatography or ERCP evidence of CBD stones were included. Patients with evidence of cholangitis (right- hypochondrial/epigastric tenderness, fever and rigors, and an elevated leuococystic count), pancreatitis (epigastric pain, nausea/vomiting associated with the serum amylase level elevated 3 times over the normal range), postcholecystectomy patients, and patients with contraindication to laparoscopy (marked liver cirrhosis, pregnancy, ASA III/IV, upper abdominal surgery, etc.) were excluded. Operative Technique LC was carried out under general anesthesia with the patient positioned supine with the surgeon and the assistant Received for publication January 19, 2015; accepted July 9, 2015. From the Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt. The author declares no conflicts of interest. Reprints: Ehab Atif, MD, MRCS En, Gastroenterology Surgical Center, Mansoura University, Jehan St, Mansoura, Dakahlia 35516, Egypt (e-mail: dr.ehab.atif@gmail.com). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. ORIGINAL ARTICLE e152 | www.surgical-laparoscopy.com Surg Laparosc Endosc Percutan Tech  Volume 25, Number 5, October 2015 Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.