الفهرس 
EMBRYOLOGY AND ANATOMY OF THE BILIARY TRACT AND GALL BLADDEROnly 14 pages are availabe for public view
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Abstract
Common bile duct (CBD) stones continue to pose a significant problem both to the patient and the surgeon. They increase the morbidity of a patient undergoing cholecystectomy from less than 3% to as much as 10% and almost zero mortality to as high as 30%, (Petelin, 2003).
Patients presenting with CBDS have symptoms including: biliary colic, jaundice, cholangitis, pancreatitis or may be asymptomatic, (Hungness et al, 2006).
It is important to distinguish between primary and secondary stones, because the treatment approach varies. Stones found before, during, and after cholecystectomy had also differing treatments, (Hungness et al, 2006).
Different methods have been used for the treatment of CBDS but the suitable therapy depends on conditions such as patient’ satisfaction, number and size of stones, and the surgeons experience in laparoscopy, (Petelin, 2003).
Endoscopic retrograde cholangiopancreatography with or without endoscopic biliary sphincterotomy, laparoscopic CBD exploration (transcystic or transcholedochal), or laparotomy with CBD exploration (by T-tube, C-tube insertion, or primary closure) are the most commonly used methods managing CBDS, (Hungness et al, 2006).
The management of choledocholithiasis has changed radically since the introduction of laparoscopic cholecystectomy. However, perceived technical difficulties have deterred many surgeons from treating common bile duct stones laparoscopically at the time of cholecystectomy. This has lead to reliance on endoscopic retrograde cholangiopancreatography followed by endoscopic sphincterotomy to deal with common bile duct stones, (Petelin, 2003).
Recent studies indicate that one-stage management of CBD stones with LCBDE has less morbidity and mortality and is cost-effective with a short hospital stay. It treats both gallstones and CBD stones in single stage compared with sequential procedures, and is performed as a daycare procedure, (Tai et al, 2004).
Performing ERCP contextually to LC implies organizational problems concerning the availability of an endoscopist in the operating theater whenever needed. Finally, performing ERCP after surgery would raise the dilemma of managing CBD stones whenever ERCP fails to retrieve them because a third procedure would then be needed, (Hungness et al, 2006).
CBD stones are usually treated with sequential treatment by EST followed by laparoscopic cholecystectomy. However, recent studies indicate that single stage laparoscopic management might be the preferred option in established centres especially if the patient has multiple stones with a dilated CBD. It does not cause any damage to the sphincter of Oddi, which has been shown to result in cholangitis and recurrent CBD stones, (Petelin, 2003).
In patients presenting with cholangitis and jaundice, it may be advisable to relieve the biliary obstruction by EST and then perform laparoscopic cholecystectomy, (Hungness et al, 2006).
If laparoscopic experience is limited, it is advisable that CBD stones should be removed by either pre or postoperative EST and laparoscopic cholecystectomy, (Tai et al, 2004).
Finally if laparoscopic exploration fails it is prudent to convert to open exploration of CBD, remove the ductal stones and perform a biliary drainage procedure if indicated, (Tai et al, 2004).