This study demonstrates that intraoperative lithotripsy significantly altered operative strategy in LBDE. Before the availability of lithotripsy, LBDE in patients with large, multiple, or impacted stones relied mainly on conventional transcystic extraction techniques and choledochotomy-based exploration. In that era, choledochotomy rates were higher because stones that were too large, impacted, or not amenable to extraction through the cystic duct often required direct ductotomy for access and retrieval. The introduction of lithotripsy has enabled the fragmentation of difficult stones and has therefore increased the feasibility of duct clearance while reducing the need for choledochotomy in selected patients [4]. The most striking finding is the statistically significant reduction in choledochotomy from 34.2% to 5.2%, as shown in Table 2. This represents a substantial shift toward trans-cystic completion, a strategy consistently associated with reduced morbidity in the literature [2,6].

Operative duration was also significantly reduced, as shown in Table 3, likely reflecting avoidance of choledochotomy and the concomitant requirement for laparoscopic suturing and T-tube management [7,8]. Previous systematic reviews of laparoscopic lithotripsy techniques have demonstrated high stone clearance rates with acceptable safety profiles [9], supporting our observed reduction in operative complexity.

Although the bile leak rate was not statistically different, as seen in Table 3, no leaks occurred in 2025. Avoidance of choledochotomy and T-tube drainage may explain this observation, as choledochotomy and T-tube drainage have been associated with increased morbidity compared with primary closure [8]. Perhaps a larger study could increase the certainty and decrease the p-value, or dispute the finding.

ERCP reintervention and length of stay decreased numerically, as shown in Table 4 and Table 5, respectively, though these changes were not clinically significant. ERCP was performed within 30 days of surgery and was reserved for retained or suspected retained common bile duct stones, as well as post-operative biliary complications such as bile leaks. Prior comparative studies of single-stage management versus staged ERCP have demonstrated similar or improved outcomes with laparoscopic approaches [1,6], and our results align with these findings. Several systematic reviews and multicentre series have shown that, when feasible, the trans-cystic approach is associated with lower morbidity, shorter procedure time and shorter length of stay than transductal choledochotomy, while achieving comparable stone clearance for selected stones [8,10]. Meta-analyses specifically comparing transcystic (TC) and transductal (TD) LBDE report lower overall morbidity, fewer biliary complications, and shorter operative times with TC approaches [10,11]. Those pooled data emphasise that adjuncts such as choledochoscopy, baskets, balloon extraction and intracorporeal lithotripsy increase the proportion of patients amenable to TC clearance [3,11,12].

Our unit-level results mirror the effect described in the literature for centres that systematically adopt adjunctive instruments: series reporting Holmium: YAG (and other) intracorporeal lithotripsy during LBDE describe improved transcystic success in impacted or large stones that formerly required choledochotomy, with high clearance rates and acceptable complication profiles [10-12]. The systematic review of holmium laser use in LBDE summarises stone-free rates that are consistently high when laser lithotripsy is used as an adjunct to choledochoscopy, supporting the mechanistic basis for our observed reduction in choledochotomy [10].

Cochrane and other high-quality reviews addressing single-stage surgical approaches vs endoscopic staged care or T-tube drainage similarly support the safety and effectiveness of LBDE in experienced hands, and question routine T-tube use because of added morbidity and resource use [1,12-14]. Our findings of reduced choledochotomy/T-tube usage and no increase in short-term complications are concordant with those systematic conclusions.

Limitations

It is important to note that these results reflect whole-unit practice change rather than isolated lithotripsy cases. The marked reduction in choledochotomy rate demonstrates a clear strategic shift. These findings support routine lithotripsy availability in units performing LBDE, consistent with modern guideline recommendations supporting advanced laparoscopic biliary techniques [6]. 

Although the present study primarily evaluated perioperative and short-term outcomes, longer-term issues after bile duct exploration and lithotripsy may include recurrent ductal stones, biliary stricture, cholangitis, and late presentations of retained fragments. We acknowledge that a longer follow-up would be valuable to better assess these outcomes.

The study was limited to one hospital, which means that not only is the study limited in the number of different surgeons performing the operations, and so surgeons' preference in technique can't fully be excluded, but also, the number of patients included was limited, which affects the certainty of the results and is reflected in the p-value. The same ratios of different bile leakages, for example, could have had more certainty and therefore a significant p-value, had more data been utilised. Another limitation is the modest difference in patient age between groups, with the lithotripsy cohort being slightly younger, which may have influenced perioperative outcomes. A future suggestion of this trial would be to examine a similar change over multiple hospitals. This may support or dispute the argument of lithotripsy use in laparoscopic cholecystectomies.