Choledocholithiasis Is a Surgical Disease: The Evolution, Standardization, and Impact of Laparoscopic Common Bile Duct Exploration in the Acute Care Surgery Setting.

Abstract

Acute care surgeons can provide a "surgery first-one stop" approach to choledocholithiasis using laparoscopic common bile duct exploration (LCBDE). We describe the implementation and evolution of a catheter-based LCBDE pathway within an academic acute care surgery (ACS) practice, shifting management of choledocholithiasis back into the hands of surgeons. This retrospective analysis reviewed patients who underwent LCBDE by our ACS practice between 2019 and 2025. Before 2019, choledocholithiasis was routinely managed with ERCP either before or after cholecystectomy. A "surgery first-one stop" pathway was initiated in 2019. The LCBDE protocol leveraged fluoroscopic Seldinger techniques, flushing, balloon sphincteroplasty, choledochoscopy, and lithotripsy as indicated. Full adoption (FA) was defined as the point at which all ACS surgeons had begun to perform LCBDE. Outcomes between pre-FA (2019 to 2020) and FA (2021 to 2025) were compared, including length of stay (LOS), successful duct clearance, complications, case duration, and readmission. A total of 126 patients underwent LCBDE (34 pre-FA, 92 FA) with an overall duct clearance rate of 82.5%. Clearance rates improved significantly from 70.6% pre-FA to 87.0% FA (p = 0.042) without an increase in median operative time. Use of advanced techniques, including balloon sphincteroplasty, nearly doubled after 2020, and lithotripsy was required in 11.1% of cases. The median hospital LOS decreased from 72.1 (pre-FA) to 40 (FA) hours (p = 0.01). Complication and readmission rates remained low at 3.1% and 2.4%, respectively. Implementation of a surgeon-led "surgery first-one stop" LCBDE pathway is safe, effective, and associated with improved duct clearance and reduced LOS. Successful adoption has enabled a "surgical consultation first" strategy for suspected choledocholithiasis, placing the ownership of this disease back into the surgeon's hands.