Table 1.

Difficulty grading classification for laparoscopic bile duct exploration

Difficulty grade	Stone location	Stone number	Stone size mm	Technical factors
Grade IA	CBD	1–5	< 8	TCE, blind Basket-in–Catheter (BIC) technique
Grade IB	CBD	1–10	8–10	TCE, blind BIC; CD diameter or configuration hinder cannulation, requring further proximal incision/dilatation. Or X-Ray guidance needed to engage stones
Grade IIA	CBD	1–10	8–15	Choledochscopic TCE or Stone recovery from CD stump needs crushing or further CD incision. cystic anomalies (low or medial implantation)
Grade IIB	CBD	1–15	Up to 15	Choledochotomy with or without biliary drainage or TCE with biliary drainage
Grade IIIA	CBD or CHD	> 15	Up to 15	Choledochoscopic TCE for large distal stones or choledochotomy for large CBD or intrahepatic stones
Grade IIIB	CHD	Any	Any	TCE with choledochoscopic WBM stone retrieval
Grade IV	Any	Any	Any	TCE for Mirizzi type I/choledochotomy for impacted stones needing dislodging manoeuvres/need for antegrade stenting
Grade V	Any	Any	Any	TCE; transfistula exploration for Mirizzi II/CBDE for impacted stones needing fragmentation/open conversion/bilioenteric anastomosis e.g. Mirizzi Types III or IV

CBD common bile duct, CHD common hepatic duct, TCE transcystic exploration, BIC basket-in-catheter, CD cystic duct, WBM wiper blade manoeuvre