In recent decades, with the development of new laparoscopic techniques and devices, LC has been recognized as the gold standard for the surgical management of gallstone diseases [17]. At the same time, the treatment for CBD stones has changed, and an increasing number of options are now prevalent. These new options include ERCP, endoscopic papillary balloon dilation (EPBD), or EST (if necessary) followed by LC; LC and intraoperative transcystic or direct CBD exploration; postoperative ERCP with EPBD/EST and stone extraction; intraoperative ERCP, EPBD/EST, and stone extraction during LC; and conversion to laparotomy [18, 19]. Therefore, there are two main surgical strategies in clinical practice: a single-stage surgical strategy involving LCBDE and stone retrieval at the time of LC and an alternative option of staged procedures, with LC and ERCP on separate dates for CBD stone clearance [20].

The advantage of staged procedures is the significantly shorter surgical time, but patients are exposed to the risks associated with ERCP, such as infection, pancreatitis, hemorrhage, and perforation. In addition, delays between the two stages of treatment may result in prolonged hospital admission [20, 21]. Furthermore, both endoscopic papillary large balloon dilation (EPLBD) alone and EST + EPLBD tend to result in a persistent and comparable loss of SO function, which is a likely cause of duodenobiliary reflux, bacterial contamination of the biliary tract, and subsequent late adverse events, including stone recurrence, cholangitis, or liver abscess [22]. Finally, the greatest concern following EST is the likelihood of developing subsequent cholangiocarcinoma, and a number of authors have suggested that we be prudent to avoid a sphincterotomy in the very young until further studies clarify the situation in these patients [23]. Although both procedures are equivalent in terms of clinical outcomes, the single-stage surgical strategy can preserve the function of the SO, which effectively eliminates the potential serious risks of ERCP-associated complications and the need for further procedures [20, 24]. Moreover, the single-stage surgical strategy has a similar or better stone clearance rate, and it may be an ideal method for patients who fail ERCP because of difficult choledocholithiasis [25]. The single-stage surgical strategy has also been found to be safe and efficacious even in elderly patients [26]. Therefore, a single-stage surgical strategy is feasible and cost-effective, with a reduced length of hospital stay, and should ultimately be the preferred procedure for most patients [20, 24].

In the early stages of laparoscopy, previous abdominal surgery was widely regarded as a relative contraindication of laparoscopic surgery for the following reasons: (1) serious adhesions near the previous incision at the inner side of the abdominal wall make it possible to injure adjacent organs or tissues when inserting the first trocar or Veress needle; (2) it is difficult to distinguish and dissect extensive dense adhesions around the hepatoduodenal ligament and the CBD, which may increase the risk of injury to biliary and vascular structures at the hilar area [27]; and (3) these complex operations can be even further magnified by laparoscopy considering the lack of manual palpation and may ultimately increase the probability of conversion to laparotomy or even become a potential source of morbidity and prolonged hospital stay [27]. However, with the developments in laparoscopic techniques and technological advances in equipment, more surgeons have attempted to perform complicated laparoscopic surgeries in patients with previous abdominal surgery [28, 29]. Unfortunately, owing to the dense adhesions in the operative area, there are very few reports about laparoscopic procedures in patients with a history of abdominal biliary tract surgery. However, with the developments in laparoscopic equipment and the accumulation of experience by laparoscopic surgeons, complicated laparoscopic procedures can be performed in patients who have undergone previous biliary tract operations in our center. Based on our findings, we would object to the previous view that previous abdominal surgery is a relative contraindication for laparoscopic surgery.

In the present study, we found that the LCBDE group performed better than the OCBDE group with respect to estimated blood loss, remnant CBD stones, and postoperative hospital stay. First, the estimated blood loss of 30 (5–700) mL observed in the LCBDE group was similar to the estimated blood loss of 52 mL reported in Pang’s research [30]. The lower blood loss in the LCBDE group might be attributed to the mini-incision, clear vision, and delicate maneuvering. Second, the incidence of residual stones after LCBDE was reported to be 2% to 5% in retrospective studies of 157 patients and 170 patients, respectively [3, 31]. The present study showed that the proportion of residual stones following LCBDE was 17%, which was slightly higher than that previously reported. The patients in our study had a history of at least one abdominal biliary tract surgery, which significantly increased the difficulty of the operation in some patients. Additionally, some elderly and infirmed patients had a reduced tolerance to prolonged endoscopy surgery. Because the damage control strategy is recommended to reduce the incidence of adverse reactions resulting from prolonged endoscopy surgery, we preferred to address residual stones by choledochoscopy in the subsequent follow-up. The LCBDE group had a lower incidence of remnant CBD stones, which should be attributed to optical magnification and direct visualization. Third, a randomized prospective study by Rhodes et al. demonstrated that the median hospital stay was significantly lower in a one-stage LCBDE group than in a two-stage ERCP group (preoperative/postoperative ERCP and LC). According to a recent report, the mean postoperative hospital stay fluctuated from 2.8 ± 0.1 to 11.0 ± 6.1 days for LCBDE [3, 32]. In this study, the postoperative hospital stay was 7 (3–78) days, which compares favorably with other published studies of LCBDE. The short postoperative hospital stay in the LCBDE group might be attributed to the small incision and early time to oral intake due to the early recovery of bowel function. Fourth, a recent meta-analysis showed that the operative time was 119.5 min and the conversion rate was 9% in LCBDE, which were lower than the 170 (60–480) min and 17%, respectively, obtained in our study [18]. All the procedures (including laparotomy and laparoscopic surgery) were performed by an experienced surgeon. The main reason for the differences in the operative time and conversion rate is that a number of patients with abdominal adhesion were recruited in this study, which increased the values of these two results.

Pulmonary diseases such as pneumonia and pleural effusion seemed to be the most common postoperative complications, affecting up to 32% and 42% in the LCBDE and OCBDE groups, respectively. In the present study, 96% of patients with pulmonary disease recovered through aerosol inhalation or anti-infective therapy. Only 1 patient in the LCBDE group and 2 patients in the OCBDE group with pleural effusions recovered through ultrasound-guided local drainage. Moreover, postoperative complications such as bile leakage may become a major problem for patients who undergo LCBDE. In this study, bile leakage occurred in only 5% and 10% of patients in the LCBDE and OCBDE groups, respectively, and 82% of patients recovered through symptomatic and supportive treatment. Only 1 patient in the LCBDE group and 2 patients in the OCBDE group with bile leakage received ultrasound-guided local drainage. In addition, the incidences of wound infection and postoperative bleeding were quite low in our study and comparable to those reported by other authors [3, 33].

There is little evidence in the literature to evaluate the factors affecting the degree of postoperative adhesion in patients with previous abdominal biliary tract surgery. In this study, we assessed the feasibility and safety of LCBDE in patients following abdominal biliary tract surgery, and we found a significant difference in the previous number of operations, previous surgical approach and previous operation scope among classes zero and 1, 2 and 3 (p ≤ 0.05). After further comparison between groups with respect to the previous operation scope, we found a significant difference between previous gallbladder surgery and previous bile duct surgery and previous gallbladder surgery and previous gallbladder + bile duct surgery between classes zero and 1, 2 and 3, which suggested that patients who received cholecystectomy alone had less adhesion than those who received biliary tract surgery (including bile duct or gallbladder + bile duct). The reason many surgeons prefer OCBDE after biliary surgery is adhesion; however, our research suggests that LCBDE should also be recommended for patients with a history of cholecystectomy, few previous operations (< 2 times), or a history of laparoscopic surgery. Previous biliary tract surgery (including bile duct or gallbladder + bile duct other than cholecystectomy alone) often involves more organs and tissues, which may significantly increase the risk of postoperative adhesion. It is not surprising that multiple previous operations (≥ 2 times) were risk factors for postoperative adhesion because multiple operations always increase tissue damage and local fibrosis formation. In addition, a comparative clinical study in 26 patients suggested that laparoscopic surgery resulted in less adhesion formation, either on the operative or at the trocar entry sites, than laparotomy [15].

Here, we summarize some key points of the surgical procedure performed during our operation. (1) A reasonable location for the first trocar port is absolutely vital and should be in the periumbilicus and far from the previous incision to prevent injuring adjacent organs or tissues. The classic open technique (Hasson technique) is highly recommended for patients with previous upper abdominal biliary tract operations and is apparently much safer than the classic closed technique (Verres needle). Once the pneumoperitoneum has been established, the second trocar could be placed below the right costal margin under direct vision. (2) The adhesions between the abdominal wall and the omental tissue, abdominal wall, and internal organs and adhesions between organs or structures are always serious for patients with previous abdominal biliary tract surgery. Therefore, whether intra-abdominal adhesions could be separated without unnecessary injury is directly related to the success or failure of the surgery. Laparoscopic adhesiolysis could be implemented well by blunt and sharp dissection with the use of scissors, an ultrasonic scalpel or the head of the aspirator. We generally separated the adhesion between the abdominal wall and the omentum or the antrum first, and then we carefully separated along the liver surface to restore the anatomical structure of the normal gastric pylorus, duodenum, and duodenal ligament. The duodenum is always an anatomical landmark in the separation of adhesions. Conversion to laparotomy should be considered immediately to prevent unnecessary damage to the clear tissue spaces that could not be accessed, or complications could occur during the laparoscopy. (3) Regarding the separation of the CBD, the ‘make a breakthrough at the center and dissect on the two sides’ technique should be employed, and the CBD should be identified clearly and dissected close to the visceral surface of the liver when the hepatoduodenal ligament and the Calot triangle are dissected. If it is difficult to distinguish the CBD, the surrounding anatomic marks, such as the cystic duct stump or duodenal bulb, may be helpful. It can also be further confirmed by bile duct puncture with a syringe at the same time, and the bile can be sent for culture. (4) The upper bile duct at the junction between the cystic duct and the common hepatic duct should be selected as the incision site. Moreover, the appropriate incision is suggested according to the diameter of the choledochoscope and the size and location of the stones. It would be better to use picture-in-picture dynamic display mode with laparoscopic and choledochoscopy dual vision in the process of stone extraction, which could help reduce the incidence of bile duct injury. (5) If the stones in the CBD are large, the stones should be removed by a variety of removal methods (crushed by laparoscopic grasping forceps or fragmented by electrohydraulic lithotripsy), and then the fragmentations could be extracted rather than being removed by expanding the incision to avoid damage to the wall of the bile duct. (6) Regarding the routine flexible choledochoscope examination, if a flexible choledochoscope is used to enter the dilated intrahepatic or extrahepatic duct, care should be taken to determine whether there are any problems, including bile duct stricture and tumor or residual stones in the bile duct, and the stones—including those of the dilated bile duct—should be removed if necessary. (7) To prevent biliary fistula and promote healing of the CBD incision, the CBD should be full-thickness sutured with a 4-0 absorbable single-layer suture.

There are also some potential limitations to the present study. This was a retrospective observational study, and some key statistics could not be measured, and significant biases might have affected the selection of controls. This was minimized by analyzing a consecutive series of patients who had undergone surgery by a single surgeon. Although the outpatient follow-up period in our study was more than six months, the study still lacked long-term follow-up data to investigate long-term complications. We will overcome these shortcomings in future research.

In summary, LCBDE is a safe and effective technology for the treatment of CBD stones in patients with a history of abdominal biliary tract surgery; it is minimally invasive and has less estimated blood loss, a lower incidence of remnant CBD stones, a shorter postoperative hospital stay, and fewer complications than other CBD procedures. LCBDE should be recommended for patients with a history of cholecystectomy, few previous operations (< 2 times), or a history of laparoscopic surgery. The technology is safe, effective, and promising for clinical application as long as its indications are taken seriously and skilled laparoscopic and choledochoscopy techniques are available.