the management of stones in the common bile duct ( cbd ) is currently under much debate within the medical literature . the 3 main approaches are endoscopic retrograde cholangiopancreatography ( ercp ) , open surgery , and increasingly laparoscopic exploration of the common bile duct ( lecbd ) . however , the surgical management of difficult and recurrent choledocholithiasis in patients who have had cholecystectomy in the  open era poses a challenge , first because of the potential difficulty of significant adhesions after open surgery and second because patients often present later in life with the inherent increased risks of age and comorbidity . difficult choledocholithiasis is defined as failure of endoscopic stone retrieval for the following reasons : access and cannulation difficulty , the difficult nature of common bile duct stones , and the presence of ercp - related complications . common bile duct stones are defined as recurrent if they are detected more than 2 years after cholecystectomy . we present 3 such patients who were successfully managed by lecbd , which has not previously been reported . ercp was successful in the diagnosis of choledocholithiasis in all the patients ( figure 1 ) . lecbd was performed because cbd stones could not be retrieved during ercp because ( a ) 2 patients had large and impacted stones and ( b ) 1 patient had incomplete stone extraction despite multiple endoscopic sessions . multiple impacted stones in the cbd , could not be retrieved by ercp port sites were placed as for routine laparoscopic exploration of cbd . significant adhesions were found that were taken down by using diathermy scissors to facilitate access ( figure 2 ) . an extra 5-mm port was used for placement of a nathanson retractor to elevate the liver , thus enhancing exposure to the operative field ( figure 3 ) . the cbd was localized by aspiration of bile using a long spinal needle directly through the anterior abdominal wall . the needle was grasped intraperitoneally 5 mm from the tip before localization , thus minimizing the risk of the posterior cbd wall by excessive puncture ( figure 4 ) . the overlying peritoneum was carefully dissected , and a longitudinal incision was made in the anterior cbd wall by using an espiner knife and potts scissors ( figure 5 ) . free stones were removed by using appropriate graspers ( figure 6 ) , and choledochoscopy was performed to identify and remove residual stones , using either a dormia basket or a fogarty catheter . after clearance , the choledochotomy was closed primarily by using interrupted 2/0 vicryl in 2 patients . in 1 patient , a drain was placed adjacent to the repair in each case and removed at 48 hours . photograph showing exposure with the help of nathanson retractor . technique for minimising the chances of injury to posterior wall of cbd while aspiration . three patients have had the procedure over the past year . the demographics and clinical details are presented in table 1 . none of the patients had any complications during or after surgery . postoperative stay was not prolonged except in 1 patient who required delayed discharge ( 7 days ) because of social circumstances . it has been proven not only feasible but also effective in dealing with cbd stones . lcbde for difficult recurrent stones is a safe technique provided appropriate surgical experience and equipment are available , which is emphasized in this report . despite the potentially increased risk in this group of patients , it is associated with acceptable operative times , and minimal morbidity and duration of hospital stay .
the management of common bile duct stones has traditionally required open laparotomy and bile duct exploration . with the advent of endoscopic and laparoscopic technology in the latter half of the last century , 
 endoscopic retrograde cholangiopancreatography and laparoscopic common bile duct exploration has become the mainstream treatment for common bile duct stones in most medical centers around the world . 
 however , in some patients , endoscopic retrograde cholangiopancreatography is difficult and laparoscopy is challenging because of previous surgery . 
 these facts are highlighted in this report .