In this episode of Behind the Knife, the minimally invasive surgery (MIS) team dives deep into the evolving field of common bile duct exploration (CBDE). From the historical context of laparoscopic approaches to the latest advances including robotic-assisted techniques, Drs. Shaina Eckhouse, James Jung, Zachary Weitzner, and Joey Lew discuss key evidence shaping modern practice. Listeners will learn about indications and anatomy guiding trans-cystic versus trans-choledochal approaches, practical tips for safe stone clearance, and critical considerations around learning curves and team coordination for robotic procedures. The episode also highlights important studies comparing single-stage laparoscopic CBDE with staged ERCP and cholecystectomy, emphasizing outcomes such as stone clearance, pancreatitis rates, and hospital length of stay. This comprehensive overview is a must-listen for MIS and acute care surgeons interested in optimizing the management of choledocholithiasis and streamlining patient care with minimally invasive techniques.

Hosts:
- Shaina Eckhouse, MD, Bariatric Surgery Medical Director and Vice Chair of Clinical Operations, Department of Surgery, Duke University
- James Jung, MD, PhD, Assistant Professor of Surgery, Duke University
- Zachary Weitzner, MD, Minimally Invasive and Bariatric Surgery Fellow, Duke University, @ZachWeitznerMD
- Joey Lew, MD, MFA, Surgical resident PGY-3, Duke University, @lew__actually

Learning Goals:
By the end of this episode, listeners will be able to:
- Describe the historical approaches to managing choledocholithiasis, including staged interventions and the evolution toward single-stage laparoscopic common bile duct exploration (CBDE).
- Summarize key clinical evidence comparing CBDE and ERCP, including landmark studies and meta-analyses evaluating outcomes, complications, and trends over time.
- Distinguish between transcystic and transcholedochal approaches to CBDE, explaining indications, contraindications, and technical nuances for each technique.
- Identify appropriate candidates for transcystic exploration based on cystic duct anatomy and stone characteristics.
- Recognize the impact of newer surgical technologies—such as digital choledochoscopy, Spyglass, and robotic platforms—on CBDE practice, efficiency, and safety.
- Discuss the importance of multidisciplinary teamwork, preparation, and perioperative planning for successful CBDE, particularly in complex or altered anatomy cases.
- Appraise the learning curve and quality of evidence for new CBDE procedures, outlining the need for mentorship, ongoing training, and knowing when to collaborate with GI or hepatopancreaticobiliary (HPB) surgery.
- Outline approaches and bailout strategies for challenging cases, including patients with surgically altered anatomy and use of adjuncts such as intraoperative cholangiography (IOC), feeding tube placement, and Fanelli stents.
- Evaluate safety outcomes and limitations associated with robotic-assisted CBDE and single-stage management, incorporating recent data from population-based studies.
- Reflect on strategies for tailoring CBDE techniques to individual patient anatomy, surgeon experience, and available resources, advocating for evidence-based practice and continuous learning.

References:
- Giurgiu DI, Margulies DR, Carroll BJ, et al. Laparoscopic Common Bile Duct Exploration: Long-term Outcome. Arch Surg. 1999;134(8):839-844. doi:10.1001/archsurg.134.8.839 https://pubmed.ncbi.nlm.nih.gov/10443806/
- Lyu Y, Cheng Y, Li T, Cheng B, Jin X. Laparoscopic common bile duct exploration plus cholecystectomy versus endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for cholecystocholedocholithiasis: a meta-analysis. Surg Endosc. 2019;33(10):3275-3286. doi:10.1007/s00464-018-06613-w https://pubmed.ncbi.nlm.nih.gov/30511313/
- Bekheit M, Smith R, Ramsay G, Soggiu F, Ghazanfar M, Ahmed I. Meta‐analysis of laparoscopic transcystic versus transcholedochal common bile duct exploration for choledocholithiasis. BJS Open. 2019;3(3):242-251. doi:10.1002/bjs5.50132 https://pubmed.ncbi.nlm.nih.gov/31183439/
- Cironi K, Martin MJ. Reclaim the duct! Laparoscopic common bile duct exploration for the acute care surgeon. Trauma Surg Acute Care Open. 2025;10(Suppl 1). doi:10.1136/tsaco-2025-001821 https://pubmed.ncbi.nlm.nih.gov/40255986/
- Zhang C, Cheung DC, Johnson E, et al. Robotic Common Bile Duct Exploration for Choledocholithiasis. JSLS J Soc Laparosc Robot Surg. 2025;29(1):e2024.00075. doi:10.4293/JSLS.2024.00075 https://pubmed.ncbi.nlm.nih.gov/40144383/
- Kalata S, Thumma JR, Norton EC, Dimick JB, Sheetz KH. Comparative Safety of Robotic-Assisted vs Laparoscopic Cholecystectomy. JAMA Surg. 2023;158(12):1303-1310. doi:10.1001/jamasurg.2023.4389 https://pubmed.ncbi.nlm.nih.gov/37728932/

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