The cholecystectomy can be completed if cholangiography is negative. However, there are several options when the cholangiogram at laparoscopy shows stones. It may be legitimate to leave some very small stones to pass spontaneously. Careful prospective collection of data will document the density of traffic on each road in the algorithm. This will be determined by the accuracy of predicting the presence or absence of duct stones before laparoscopy and especially by the efficiency and safety of endoscopy and sphincterotomy.
Endoscopic results depend greatly on experience, which is geographically variable.
Also troublesome is the risk of sphincterotomy in patients with ducts of normal caliber. It is received wisdom within the endoscopic community that sphincterotomy is more dangerous with small ducts, but few data are available. The higher perforation rate after endoscopic sphincterotomy in patients with papillary stenosis is probably related at least partly to the fact that the duct is often not dilated. This discussion so far assumes that laparoscopic cholecystectomy itself is always successful and safe. There are other practical issues.