الفهرس 
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Abstract
The reported incidence of common bile duct stones (CBDS) varies between 5and 12%. The risk factors include congenital, biological, and behavioural factors. Bile stasis and infection are important factors for primary CBD-stone formation. Common bile duct stones may occur due to passage of a stone from the gallbladder, or arise de novo in association with biliary strictures, infection, duodenal diverticula or foreign material.
CBD stones are classified into: Cholesterol stone and Bilirubin stone( Black-pigment stone and Brown-pigment stone ).
Bile duct stones (BDS) are often suspected on history and clinical examination alone but symptoms and signs of common bile duct stones (CBDS) are variable and can range from being completely asymptomatic to complications such as biliary colic, jaundice, cholangitis or pancreatitis. The diagnostic investigations include: A- Laboratory tests:
Patients presenting with CBDS often have cholestatic liver function tests B- Common Bile Duct imaging:(1- Ultrasound (USS):2- CT scan:3- MRCP 4- Endoscopic Ultrasound (EUS): 5- Laparoscopic Ultrasound (LUS): 6-Intra Operative Cholangiogram (IOC): 7- Endoscopic Retrograde Cholangiopancreatography (ERCP)).
By using factors such as age, liver test results, and ultrasonographic(US) findings, patients can generally be categorized into low (<10%), intermediate (10%-50%), and high (>50%) probability of choledocholithiasis.A CBD stone seen on US is the most reliable predictor of choledocholithiasis. Otherwise, the most predictive variables seem to be cholangitis, a bilirubin level higher than 1.7 mg/dL, and a dilated CBD on US. The presence of 2 or more of these variables results in a high probability of a CBD stone and it is recommended to do preoperative endoscopic retrograde cholangio pancreatography( ERCP)
While Advanced age (older than 55 years), elevation of a liver biochemical test result other than bilirubin, and pancreatitis are less robust predictors for choledocholithiasis, in these cases, magnetic resonance cholangiopancreatography(MRCP) or endoscopic ultrasonography (EUS) are sensitive and specific methods for detecting CBDS, on the other hand, non jaundiced patients with a normal bile duct on US have a low probability (<10%) of choledocholithiasis and they undergo laparoscopic cholecystectomy and intraoperative cholangiography(IOC).
There are many approaches for the management of choledocholithiasis associated with symptomatic gallstones: (1) ERCP followed by laparoscopic cholecystectomy (LC); (2) intraoperative laparoendoscopic “rendezvous” (LER) or laparoscopic antegrade sphincterotomy (LAS); (3) LC and laparoscopic CBD exploration (LCBDE) by choledochotomy; (4) transcystic stone removal during LC; (5) LC followed by postoperative ERCP; and (6) open cholecystectomy + choledochotomy ± transdudenal papillatomy if any of the procedures described above are unsuccessful.
If Stones suspected preoperatively: The clinician must decide whether to attempt common duct stone removal before operation, i.e., endoscopic retrograde cholangiography and extraction with or without sphincterotomy (ERC ± S) or to proceed directly with LC and LCDE.
If Stones discovered intraoperatively: 4 options exist: (1) perform laparoscopic LCDE, (2) perform intraoperative ERCP or antegrade sphincterotomy, (3) convert the case to open common duct exploration and choledocholithotomy, or (4) leave the stones in place for removal at a postoperative ERCP. LCBDE in experienced hands appears to be the most cost-effective method for treating CBDS, it is a procedure that requires clinical experience as well as advanced laparoscopic skills. if such skills are not available among the staff at the hospital, open CBDE or postoperative ERCP should be considered. Postoperative ERCP necessitates a second procedure and there is a risk that it will be unsuccessful, requiring reoperation. Open exploration still has its associated morbidity.