In this study, we compared two procedural sequences for single‑session management of concomitant CCL: the ERCP‑first approach followed by LC, versus the LC‑first strategy followed by intraoperative ERCP. We found that both approaches achieved high rates of CBD clearance, with acceptable complication profiles. However, the LC‑first sequence was associated with shorter operative time, lower conversion rates to open surgery, shorter hospital stay, and reduced cost. These results add to a growing body of evidence favouring an LC‑first, single‑stage approach, especially when the operation is conducted by a surgeon with combined laparoscopic and endoscopic expertise [7,14-17].

Previous studies have consistently reported CBD clearance success rates of 93%-100% for single‑session combined ERCP and LC, with no significant difference based on procedural sequence [13,18-20]. Sayed et al. reported similar findings (95.7% vs. 88.2%) in a comparable population [14]. In our study, CBD clearance rates were high in both groups (95.7% vs. 87.5%), with a slightly higher rate in the LC‑first group, although the difference was not statistically significant.

However, the 12.5% failure rate observed in the ERCP‑first group in our study necessitated stent placement or conversion to open CBD exploration. This raises the possibility that performing ERCP before cholecystectomy may delay the recognition of unfavorable anatomy or large, impacted stones until after endoscopic maneuvering has been completed [19]. Conversely, the LC‑first strategy allows early access to the cystic duct, facilitating the use of the rendezvous cannulation technique. Previous reports corroborate this benefit, demonstrating higher cannulation success rates and lower PEP rates with this approach [13,16,21].

In our study, total operative time was significantly shorter in the LC‑first group (mean 69.8 ± 22.1 vs. 83.3 ± 13.5 minutes, p < 0.001). The mean LC duration was also shorter in the LC‑first group (38.4 ± 13.2 vs. 41.2 ± 8.98 minutes, p = 0.046), while ERCP duration did not differ significantly (37.4 ± 11.4 vs. 43.3 ± 11.8 minutes, p = 0.122). However, this finding should be interpreted with caution, given the limited sample size and the later timing of the LC‑first group, which may reflect increased surgeon experience; nevertheless, the magnitude of the difference is unlikely to be explained solely by a learning effect. Our findings are consistent with the randomized controlled trial by Sayed et al., who reported total operative times of 75.1 ± 19.3 vs. 81.9 ± 16.7 minutes for the LC‑first and ERCP‑first sequences, respectively [14]. Sahoo et al. similarly found that single‑stage rendezvous procedures were faster than two‑stage approaches [17]. This difference is likely multifactorial. First, performing ERCP before cholecystectomy causes bowel distension from air insufflation [7]. In our study, this was directly implicated in four of the seven conversions in the ERCP‑first group. Such distension can obscure the hepatocystic triangle and increase dissection difficulty. Second, completing the cholecystectomy first allows the surgeon to proceed to ERCP in a decompressed and unencumbered operative field [12]; although CO₂ insufflation during ERCP partially mitigates distension, it does not eliminate it.

Nevertheless, the LC‑first approach carries inherent trade‑offs. Committing to cholecystectomy before confirming successful CBD clearance risks losing cystic duct access for a rendezvous procedure if cannulation fails, potentially necessitating repeat ERCP or conversion to open surgery [17,22]. Additionally, this sequence often requires repositioning the patient from supine to prone or left lateral decubitus (or performing ERCP in the challenging supine position), which adds time and demands specialized expertise.

While the conversion rate was numerically higher in the ERCP‑first group (8.8% vs. 2.9%) in our study, this difference was not statistically significant. This trend parallels the results of Morino et al. (18% vs. 0%) [23], who found a significantly higher conversion rate after preoperative ERCP compared to rendezvous techniques. The physiologic effects of ERCP, which include air insufflation and fluid shifts, may predispose to difficulty performing the subsequent cholecystectomy laparoscopically.

A relevant consideration in evaluating the LC‑first approach is its facilitation of the laparoendoscopic rendezvous (LERV) technique. Although our study did not formally quantify the use of this technique, the LC‑first sequence inherently enables it. Several studies have demonstrated that the rendezvous technique reduces the incidence of PEP compared with preoperative ERCP: Morino et al. reported rates of 2% versus 15% [23], Lella et al. reported 0% versus 10% [15], and Koiava et al. reported a PEP rate of 3.75%, with 100% CBD clearance, in a series of 80 patients undergoing LERV [24]. The mechanism is well characterized: guidewire passage through the cystic duct into the duodenum provides a defined path for cannulation, reducing repeated attempts at the papilla and minimizing trauma to the pancreatic orifice [16,25]. Our observation of a lower PEP rate in the LC‑first group (2.9% vs. 5.0%), though not statistically significant, is consistent with this proposed mechanism.

Despite these favorable findings, the LC‑first approach is not universally adopted. The primary barrier is logistical: coordinating laparoscopic and endoscopic teams in a single operative session can be challenging in institutions where endoscopy suites and operating rooms are separate, leading to scheduling inefficiency [26]. Additionally, some evidence suggests that the two‑stage approach (ERCP followed by LC) remains safe and effective. A meta‑analysis by Lyu et al. found that, while single‑stage approaches reduced hospital stay and cost, overall morbidity and mortality did not differ significantly from those of two‑stage management [9]. Patient selection also remains important, as emphasized by early reports on same‑session procedures [7,27].

Our study addresses this logistical concern by employing a dual‑skilled surgeon model, which eliminates the need for inter‑team coordination. This integrated approach is gaining recognition and has been validated in larger series, including La Barba et al.'s report of 200 patients treated with a single‑team laparoendoscopic approach, with favorable outcomes [28].

In this study, there were no residual stones requiring reintervention in the LC‑first group (0% vs. 3.8% in the ERCP‑first group). Although not statistically significant, this may reflect a benefit of performing ERCP after cholecystectomy, which prevents stone migration from the gallbladder to the CBD in the interval between procedures [14].

The LC‑first group also experienced a shorter hospital stay (one vs. three days) and reduced cost ($1,100 vs. $1,300). These findings are in line with the economic evaluation by Garbarini et al., who observed a mean cost reduction of approximately €1,000 per patient with the LERV approach compared to two‑stage management, primarily as a result of shorter length of stay [29], and with Poulose et al., who reported that single‑stage management was the cost‑dominant option for choledocholithiasis [30].

Study limitations

This study has several limitations. First, the retrospective, non‑randomized design introduces selection and information bias. The ERCP‑first approach predominated in the earlier study period, and the LC‑first approach in the later period, confounding outcomes with the learning curve and evolving perioperative care over the five‑year interval; a sensitivity analysis by year was not feasible given the sample size. Second, the single‑center, single‑surgeon design limits generalizability, as outcomes may differ in settings where ERCP is performed by separate gastroenterology teams. Third, the absence of multivariate regression analysis precludes adjustment for potential confounders, such as age, stone size, and ASA classification. Fourth, the final sample size (80 in Group A and 70 in Group B) fell short of the target enrollment of 108 patients per group (238 total) calculated from the literature [14], likely underpowering the study for the detection of differences in operative time as small as 6.8 minutes and for rare secondary outcomes. Fifth, cost estimates are based on institutional charges and may not be generalizable across different reimbursement models. Finally, long‑term follow‑up and patient‑reported outcome measures were not collected, limiting our understanding of late complications, stone recurrence, and patient experience.