This study has a reintervention rate due to postoperative complications of 1.6% in spite of a high emergency workload, routine cholangiography, the adoption of index admission surgery for all comers and single session management of bile duct stones. Although most reinterventions occurred in patients who had undergone bile duct explorations with or without biliary drainage, the incidence of those directly related to biliary drainage was much lower than in studies advocating primary closure of choledochotomies. Reinterventions following single session bile duct exploration have to be seen in the context of the complications and reinterventions associated with the currently used staged management of bile duct stones. The reintervention rate in our cohort of patients undergoing LC alone was 0.8%.

A comparison between the group of patients needing reinterventions and the rest of the series shows that certain preoperative characteristics have predictive significance, e.g. emergency admission and presentation with jaundice. Certain operative findings during the original procedure such as difficulty grades 4 and 5, a contracted gallbladder, bile duct stones necessitating bile duct exploration and the need for open conversion also have significant associations with reintervention (Table 4).

A systematic review was conducted in 2018 including 233 studies to identify range and consistency of definition of reported complications following LC. The study found open conversions to be the most common reported complications (58% of studies) followed by bile leakage in 38% and bile duct injury in 32%. 42% of the included studies reported reinterventions following LC [9]. This demonstrates that despite LC being the standard treatment for gallstone disease, further reintervention for postoperative complications is occasionally required and should, therefore, be included in the consent process.

Although the current study had a high workload of biliary emergencies and subsequently a high percentage of difficult cholecystectomies, the morbidity rates for the whole study [6] were lower than many published studies [10–16]. Laparoscopic CBDEs were also performed in the emergency cohort with a low reintervention rate compared to other studies on CBDE [11–18] as shown in Table 5.

The benefits of delivering an emergency biliary service in this study are reflected in a low reintervention rate for cholecystectomies done without bile duct explorations. In a cohort of 32,785 LCs, Ros et al. [1] reported a significantly higher incidence of 1% reinterventions during readmissions within one year of discharge between 1992 and 1995. In addition, reoperations post bile duct surgery, reconstruction or anastomosis between the bile duct and gastrointestinal tract, and reoperation for unspecified reasons were found increased upon the introduction of LC. There was a tenfold increase in endoscopic and percutaneous reinterventions compared to open cholecystectomy. However, the data were collected from 1987 to 1995 when most surgeons performing LC were in the learning phase of the new technique.

In the current study, where IOC is routinely performed, less than 1.6% of the patients who underwent LC with or without CBDE had complications requiring reintervention including postoperative ERCP in only 1.1% of the series. On the other hand, Ragulin-Coyne et al. [19] found that routine IOC was associated with a higher rate of complications and additional cost. However, their complications were mainly due to post-operative infections (4.3%) and the additional reintervention procedures (included ERCP in 15.8% and CBDE in 2.6%). It is likely, therefore, that routine IOC ± CBDE, as would be the case in a specialised unit, would have prevented most of these reinterventions. Li J et al. [20] suggested that where routine IOC was performed, one ERCP was avoided for every 18.5 IOCs performed.

Preoperative ERCP remains the main method of clearing CBD stones in most units. However, our results showed that one session laparoscopic management of biliary stones is associated with lower morbidity than published results of ERCP, a finding which was consistent with several studies [18–23]. Kadam et al. [21] reported lower morbidity for LC and CBDE, with bile leakage occurring in 6.7%, while two-stage ERCP/ stenting + LC was associated with 16.7% pancreatitis and 6.7% cholangitis. There was a high rate of reintervention in the ERCP group with 2.3 procedures per patient. A systematic review by Kenny et al. [22] concluded that a single-stage approach to managing symptomatic gallstones and CBD stones is the preferred procedure. Rogers et al. [23] prospectively randomised LC and laparoscopic CBDE against ERCP and found that CBDE eliminated the risk of post-ERCP pancreatitis and the need for further procedures. Gupta et al. [24] also found that ERCP involved more reinterventions than one-stage treatment of bile duct stones. Laparoscopic CBDE also reduces the incidence of recurrent stones, thus avoiding inevitable future reinterventions [25, 26].

In spite of its benefits, biliary drainage is still a main cause of morbidity following bile duct exploration. In this series of 5740 LC, 527 (9.2%) had CBDE with biliary drainage (transcystic or T-tubes) resulting in 6 reinterventions (1%): 5 relaparoscopies and 1 ERCP. However, biliary drainage following choledochotomy helped to minimise the risk of bile leakage, and to obtain postoperative cholangiography. In this study biliary drains were used to clear a few retained stones, flushing the bile duct after Glucagon administration and to dissolve blood clots in the bile duct using Alteplase, a fibrinolytic agent, thus avoiding invasive reinterventions. The use of the T-tube track to remove retained stones was first reported in 1978 by Burhenne [27], but endoscopic reinterventions have reduced the reliance on this technique. On the other hand biliary drains can result in complications. Gillatt et al. [28] reported bile leakage upon removal of the T-tube in 18% but only one of 39 patients required reoperation due to bile peritonitis. Sharma et al. [29] reported one patient (2.5%) and Wills et al. [30] had T-tube complications in 15.3% with a quarter requiring surgical reinterventions. Biliary drain complications are thus associated with a low reintervention rate reflecting the fact that most such complications can be managed conservatively.

12 patients (0.02%) in this series were found to have pancreatic, periampullary or gallbladder cancers that required postoperative reintervention. Eight needed ERCP for stenting and 4 underwent Whipple’s procedures. In systematic reviews, unsuspected gallbladder cancer was found by Choi et al. [31] in 0.7% and by Soreide et al. [32] in 0.25%–0.89% routine LCs.

The incidence of bile duct injury varies in the literatures [31–35]. In the current study, two CBD injuries (0.03%) occurred and were identified intraoperatively. IOC outlined the biliary anatomy and helped to avoid making the injury worse. Biliary stents and abdominal drains were inserted and the patients were referred to a tertiary liver surgery unit where uneventful biliary reconstruction was carried out within 24 h. Tornqvist et al. [36] quoted an incidence of bile duct injury between 0.2% and 0.9%, while Viste et al. [37] reported a frequency of 0.4% of main bile duct injury. The low biliary injury rate seems to have been contributed to, at least in part, by routine IOC, which in the context of a specialised service is safe in all elective and emergency patients.