Step-by-step laparoscopic transcystic common bile duct exploration in choledocholithiasis: technical tips, special scenarios, lessons and results from over 100 cases

Abstract Background Laparoscopic transcystic bile duct exploration has progressively evolved as an effective single-stage approach for the management of choledocholithiasis in patients with gallbladder in situ. Although endoscopic retrograde cholangiopancreatography followed by cholecystectomy remains widely practiced, growing evidence supports the transcystic approach as a safe, minimally invasive, and cost-effective alternative. Methods We present a standardized, step-by-step description of the laparoscopic transcystic technique developed through our experience in over 100 consecutive patients. The procedure is detailed, including the management of specific intraoperative scenarios. Technical tips and tricks are provided to optimize performance in cases of narrow cystic ducts, impacted or large stones, prior biliary prostheses and complex inflammatory conditions. In addition, we developed a learning-curve modeling framework to quantify how surgical experience influences key outcomes and to estimate the procedural volume required to achieve reproducible and acceptable results in other centers adopting this technique. Results The standardized technique proved feasible and reproducible across a broad range of clinical presentations. The transcystic approach allowed successful clearance of the bile duct in the vast majority of patients. Our cumulative experience demonstrates that the technique can be safely adopted regardless of cystic duct diameter, number or size of stones, or patient characteristics. Conclusion The transcystic approach represents a valid, safe, and reproducible first-line technique for choledocholithiasis in patients with gallbladder in situ. Its standardization facilitates consistent outcomes and significantly shortens the learning curve, enabling its adoption as a routine practice in centers experienced in advanced laparoscopic biliary surgery.