# Impact of Routine Intraoperative Lithotripsy on Surgical Strategy and Outcomes in Laparoscopic Bile Duct Exploration: A Single-Centre Cohort Study

## TL;DR

Using routine intraoperative lithotripsy during laparoscopic bile duct surgery reduced the need for more invasive procedures and shortened operation times.

## Contribution

This study demonstrates that routine intraoperative lithotripsy changes surgical strategy and improves outcomes in bile duct stone removal.

## Key findings

- The choledochotomy rate dropped from 34.2% to 5.2% after introducing lithotripsy.
- Median operative time decreased from 159 minutes to 120 minutes.
- Bile leak rates fell to zero in the lithotripsy era.

## Abstract

Background

Laparoscopic bile duct exploration (LBDE) enables single-stage management of common bile duct (CBD) stones. However, large or impacted stones often necessitate choledochotomy, which is associated with increased morbidity and longer operative duration. In 2025, routine intraoperative lithotripsy was introduced in our unit to facilitate trans-cystic stone clearance.

Aim

To evaluate the impact of routine intraoperative lithotripsy on operative approach and perioperative outcomes by comparing cases performed in 2025 with those performed between 2020 and 2024.

Methods

A retrospective cohort study was conducted of all consecutive patients undergoing LBDE between January 2020 and December 2025 at a single upper gastrointestinal surgical unit. Patients were divided into two groups: pre-lithotripsy era (2020-2024) and lithotripsy era (2025). The primary outcome was the rate of choledochotomy. Secondary outcomes included operative time, bile leak, endoscopic retrograde cholangiopancreatography (ERCP) reintervention, and length of stay. Categorical variables were compared using chi-square testing and continuous variables using Mann-Whitney U testing.

Results

A total of 301 patients were included (2020-2024: n=225; 2025: n=76). The choledochotomy rate decreased significantly following the introduction of lithotripsy (34.2% (n=77) vs 5.2% (n=4), p<0.001). Median operative time reduced from 159 minutes to 120 minutes (p=0.005). No bile leaks occurred in 2025 compared with 2.7% (n=6) in the earlier cohort (p=0.335). There were no significant differences in ERCP reintervention (7.6% (n=17) vs 5.3% (n=5.3), p=0.75) or length of stay (median 2 vs 3 days, p=0.14).

Conclusion

Routine intraoperative lithotripsy significantly reduced the need for choledochotomy and shortened operative duration. Its introduction has transformed surgical strategy toward near-universal trans-cystic completion with fewer post-operative complications.