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

BACKGROUND: 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. STUDY DESIGN: This retrospective analysis reviewed patients who underwent LCBDE by our ACS practice between 2019-2025. Prior to 2019, choledocholithiasis was routinely managed with endoscopic retrograde cholangiopancreatography (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 preFA (2019-2020) and FA (2021-2025) were compared, including length of stay (LOS), successful duct clearance, complications, case duration, and readmission RESULTS: 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% preFA 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. Median hospital LOS decreased from 72.1(preFA) to 40 (FA) hours (p=0.01). Complication and readmission rates remained low at 3.1% and 2.4%, respectively. CONCLUSIONS: 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.