All patients had a clear preoperative diagnosis of calculous cholecystitis combined with common bile duct stones and no contraindications to laparoscopic surgery. There were five groups: laparoscopic transcystic common bile duct exploration (LTCBDE) group; laparoscopic choledochotomy (LD ) + T-tube drainage (TD) group; LD + primary suture (I) group. drainage, TD) group; LD + stage I suture (primary suture, PS) group; endoscopic sphincterotomy (endoscopic sphincterotomy +T tube, EST) + laparoscopic cholecystectomy (laparoscopic cholecystectomy LC) Endoscopic nasobiliary drainage (endoscopic nasobiliary drainage, ENBD) + LD group. 1, LTCBD group Inclusion criteria for this group: 1) clear preoperative diagnosis of calculous cholecystitis combined with common bile duct stones, or LC intraoperative imaging of common bile duct stones; 2) diameter of common bile duct stones <8 mm; 3) no history of acute cholecystitis or cholangitis attacks within 2 weeks, no history of upper abdominal surgery; 4) clear number of common bile duct stones less than 5. Procedure: The patient's position and Trocar position were the same as that of the four-hole method LC. The triangle of the gallbladder was dissected first, and a cholangiogram was performed by inserting a contrast tube through the choledochal duct to determine the course of the bile duct and the location and number of stones in the common bile duct, then the 1/2 circumference of the choledochal duct was transected 0.5-1.0 cm from the common bile duct, and the choledochal duct was dilated with a biliary probe or balloon, and an ultra-fine cholangioscope was inserted through the dilated choledochal duct. After stone extraction, the cystic duct will be clamped shut and the gallbladder will be removed after disconnecting the cystic duct. 2. LD+TD group The selection criteria for this group were basically the same as those for open choledochotomy, with no contraindications to laparoscopic surgery and no end-stenosis of the bile duct. Surgical method: The patient's position and Trocar position were the same as that of the four-hole LC. The anterior wall of the common bile duct was incised longitudinally with a laparoscopic choledochotomy knife, and the choledochoscope was inserted to explore the common bile duct and remove the stone, and a T-tube was placed to drain the stone and remove the gallbladder hole. 3, LD+ PS The inclusion criteria for this group: 1) no heavy cholangitis requiring biliary drainage and decompression; 2) common bile duct diameter >8 mm; 3) intraoperative stone removal and common bile duct patency. The method of common bile duct dissection for stone extraction and removal of gallbladder was the same as above. The bile ducts were closed with 3-0 absorbable sutures in stage I. Interrupted full-layer or continuous full-layer sutures were used with a stitch distance and margin of about 1,5 mm. 4. EST + LC We generally apply to cases with suspected lower biliary stricture and common bile duct stones <2,5 cm in diameter. Duodenoscopy was inserted into the descending duodenum, and cholangiography was performed through the main papillary opening, and after visualization of common bile duct stones, the cholangiogram was performed under the guidance of a guide wire. After the choledocholithiasis was revealed, the papilla was incised 1.0-1.5 cm under the guidance of a guide wire, and the stone was removed directly with a stone extraction basket. After no abnormalities during the observation period, LC was performed to treat the gallbladder stones. 5.ENBD +LD This protocol is suitable [4,5] for extrahepatic bile duct stones combined with cholangitis of biliary origin, acute cholangitis, Mirizzi syndrome and duodenoscopic stone extraction failure but successful ENBD, LD was performed.Patients were first endoscopic nasobiliary drainage and LD was performed to remove the common bile duct stones after the condition stabilized.T-tube was placed in this group. Open choledochotomy with T-tube drainage has always been the standard procedure for the treatment of extrahepatic bile duct stones, but this procedure is very invasive, and T-tube drainage can cause a large loss of bile resulting in water-electrolyte acid-base imbalance, and T-tube irritation of the bile duct aggravates inflammation and edema and other related complications. In contrast, there are many methods for minimally invasive treatment of extrahepatic bile duct stones, each with its own advantages and disadvantages, so it is especially important to develop a systematic laparoscopic combined with endoscopic minimally invasive treatment of extrahepatic bile duct stones ladder treatment protocol to guide clinical work. The LTCBDE protocol utilizes the abandoned natural duct of the bile cystic duct to complete the exploration and extraction of extrahepatic bile ducts, avoiding the injuries and complications associated with open abdomen, incision of the common bile duct, indwelling T-tube, and incision of the sphincter of Oddi. lithotomy shortened the number of hospital days and recovery time compared to choledochotomy and was similar to laparoscopic cholecystectomy, which is consistent with our statistics. However, this option is technically demanding for the treatment of common bile duct stones and has strict indications. We experienced the following: 1) the choice of ultra-fine fiberoptic choledochoscope to facilitate access to the bile duct via the cystic duct, we applied a 3, 7 mm diameter choledochoscope; 2) the anatomy of the cystic duct is important, if the cystic duct is very short or long in parallel with the common bile duct, the surgical approach should be changed. (3) The transcystic duct cholangiogram is performed first to understand the bile duct course and the location and number of stones in the common bile duct, which is more difficult when the stones are located in the bile duct above the opening of the cystic duct; (4) Intraoperative transcystic duct cholangiogram is performed after lithotripsy, if necessary, to determine the absence of residual stones, blood clots obstruction, etc. The LD+TD protocol has a wide range of indications, avoids opening the abdomen, causes less disturbance to the gastrointestinal tract than open surgery, reduces surgical trauma, and has a high stone removal rate. However, there are also the following shortcomings: because the postoperative abdominal cavity is less disturbed after LD, it is not easy to form adhesions, so we leave the T-tube for a longer period of time, usually 4-8 weeks, and may have T-tube-related complications, which cannot resolve papillary stenosis. After years of clinical practice, we have developed a set of stone extraction methods: 1) remove stones near the incision with stone extraction forceps after incision of the common bile duct; 2) flush the bile duct with a flushing suction, some stones can be flushed out or loosened; 3) use stone extraction forceps directly to remove stones from the bile duct through the subxiphoid trocar opening; 4) finally use choledochoscopy to explore the bile duct and remove stones with a stone extraction mesh basket if there are stones. The advantage of the LD+PS protocol is that although the common bile duct has to be incised, the I-stage suture of the common bile duct can maintain the pressure in the bile duct, open the sphincter of Oddi, reduce the chance of inflammatory adhesions, avoid the complications associated with leaving a T-tube in place, significantly shorten the postoperative hospital stay, and reduce patient pain. However, the complications of postoperative bile leak and biliary stricture are a point of debate in the implementation of this protocol, and our report showed no statistical difference in the complication rate in our group compared with other protocols, in agreement with Decker [2] et al. Our experience is to strictly control the indications, follow the principles of stone extraction and bile duct patency, and be gentle in intraoperative choledochoscopic stone extraction. The advantages of the EST+LC protocol are high removal rate of common bile duct stones, repeatable stone extraction, and no incision of the common bile duct and placement of a T-tube after endoscopic stone extraction. However, EST and LC are two separate procedures, which increases patient pain and results in a longer postoperative hospital stay. Although there is no significant difference between our statistics of recent complications and other groups, it is important to prevent and control the serious complications of EST: bleeding, perforation, pancreatitis [9], and EST disrupts the structure of the sphincter of Oddi, which leads to easy reflux of duodenal contents into the bile duct, increasing long-term complications such as biliary tract infection and gallstone recurrence, and some reports suggest that the complication rate 10-20 years after EST is 12-24 %. Therefore, this protocol should be strictly controlled for indications, and we generally apply it to cases with suspected lower biliary strictures. ENBD +LD is a combined laparoscopic, choledochoscopic, and duodenoscopic treatment for extrahepatic bile duct stones. When LD is performed, we consider that the patient is usually in the inflammatory phase and a T-tube is always placed postoperatively. This protocol uses three scopes to treat extrahepatic bile duct stones, making full use of minimally invasive means to avoid opening the abdomen and to solve the patient's pain, but the technical requirements of this protocol are quite high, which still requires the placement of a T-tube and the possibility of damaging the structure of the sphincter of Oddi, and the indications should be strictly grasped. We generally apply it to patients with combined biliary pancreatitis, acute cholangitis and failed duodenoscopic lithotripsy with successful ENBD. In summary, we summarize a sequential treatment protocol for laparoscopic treatment of extrahepatic bile duct stones: LTCBDE avoids the injuries and complications caused by open abdomen, common bile duct dissection, indwelling T-tube and incision of the sphincter of Oddi, and should be the preferred protocol when conditions permit, and the rest are selected according to the conditions of individual patients in LD+PS, LD+TD, EST+ LC, ENBD +LD protocols in turn. We have achieved good results in the treatment of extrahepatic bile duct stones based on this protocol, which is worth promoting.