Initial experience of holmium laser lithotripsy in patients with complicated choledocholithiasis

Objective. To evaluate the efficacy and safety of choledochoscopically guided holmium laser lithotripsy in the treatment of complicated choledocholithiasis using various minimally invasive approaches.Materials and methods. A retrospective analysis was conducted of the treatment outcomes of 75 consecutive patients with complicated choledocholithiasis between 2022 and 2025. Laser lithotripsy was performed under direct visual control of a choledochoscope/cholangioscope using a holmium laser (wavelength 2100 nm) during endoscopic/percutaneous procedures in 48 patients (Group 1) or during laparoscopic cholecystectomy with bile duct exploration in 27 patients (Group 2). The frequency of complete bile duct debridement, the number of sessions, complications and length of hospital stay were assessed.Results. In Group 1, 44 patients underwent percutaneous biliary drainage followed by choledochoscopy and laser lithotripsy via the established channel; 4 underwent transpapillary cholangioscopy with lithotripsy. Complete clearance of the bile ducts was achieved in all 48 (100 per cent) patients. Clearance was achieved in a single session in 9 (20.5 per cent) of the 44 patients, whilst 35 (79.5 per cent) required 2–4 sessions. Complications were mainly associated with the establishment of percutaneous access: haemobilia was observed in 3 (6.3%) patients, and right-sided pleurisy in 1 (2.1%) patient. In Group 1, one patient died; the mortality rate was 2.1% and was due to the progression of liver failure following late presentation. In Group 2, transcystic access was used for bile duct exploration in 17 patients, and choledochotomy in 10; complete removal of stones was achieved in 26 (96.3%) patients. Temporary bile leakage, observed in 3 (11.1%) patients, ceased following endoscopic stenting. The overall rate of complete bile duct clearance, achieved in 74 out of 75 patients, was 98.7%. The mean length of hospital stay was (15 ± 4) days in Group 1, (3.6 ± 1.2) days for transcystic access and (8.6 ± 3.4) days for choledochotomy in Group 2.Conclusions. Holmium laser lithotripsy under direct choledochoscopic guidance is an effective method for clearing the bile ducts in cases of ‘complex’ stones and can be integrated into both percutaneous/endoscopic and laparoscopic procedures. Key safety requirements: adequate irrigation of the duct and continuous visual monitoring.