Different approaches are routinely applied in the treatment of concomitant cholecystocholedocholithiasis. Most patients are treated by preoperative endoscopic sphincterotomy followed by laparoscopic cholecystectomy in a two-stage approach. However one-stage approach carrying out intraoperative endoscopic sphincterotomy (IOES) is emerging as a minimally invasive alternative option. Our review evaluates the outcomes and potential advantages of IOES compared to the other therapeutic options.

An accurate enquiry for papers relating to IOES and the different available options was performed on different medical databases. Endpoints considered were: successful clearance of common bile duct stones, overall complication rate, procedure related morbidity, conversion rate, duration of hospital stay and costs.

Data were collected from 21 scientific papers including: 5 prospective randomized clinical trial, 4 Meta-analysis and 12 case series. Similar rates of successful clearance of common bile duct stones were reported between Intra Operative Endoscopic Sphincterotomy (IOES) and Pre Operative Endoscopic Sphincterotomy (POES) (96.9% versus 96.3). Overall morbidity showed no statistical significant differences between the two approaches (16.1% in two stage approach versus 19.9% in one stage approach). IOES resulted superior to two-stage approach regarding duration of hospital stay with a mean difference of 2.83 days. The shorter hospital stay ensued in a reduction of cost in most studies. No differences in conversion rate were observed between POES and IOES (3.8% versus 3.7%).

Intraoperative endoscopic retrograde cholangiography is a safe, effective and feasible treatment for patients with concomitant gallbladder stones and choledocholithiasis. This review highlighted the advantages of IOES as a minimally invasive, one-stage approach. However in order to guarantee the success of such approach a profound collaboration between surgeon and endoscopist is mandatory and an efficient logistic organization of the operating theatre is needed.