Biliary Dyskinesia/Choledocholithiasis


Welcome to the APSA Quality and Safety Committee Gallbladder Disease Toolkit. This page is intended to help anyone who is interested in Quality Improvement (QI) pertaining to gallbladder disease.

Available toolkit projects are listed below. Many of the approaches described are evidence based - some are not. These approaches have not been approved by APSA.

ERAS for Laparoscopic Cholecystectomy

The Children’s Hospital of Pittsburgh has implemented a QI project consisting of an ERAS protocol to standardize preoperative, day of surgery, and postoperative care of pediatric patients undergoing elective laparoscopic cholecystectomy with the goal of standardizing care and promoting same day discharge.



Stakeholders: pediatric surgeons, anesthesiologists/CRNAs, nursing staff (clinic, operating room, PACU)

Challenges and solutions:

  • Challenge
    • Acceptance and participation by surgeons, anesthesia staff, and nursing staff in the new protocol was a challenge.
  • Solution
    • Early engagement with staff assisted in the implementation of the protocol.

Links to published data: [1][2][3][4]

Submitted by: Marcus Malek, MD

Additional implementers: Andrew Yeh, MD

Operative First approach for Choledocholithiasis

Several institutions perform laparoscopic common bile duct exploration (LCBDE) during laparoscopic cholecystectomy as a method to provide definitive treatment for choledocholithiasis during a single anesthetic event. This section provides a comprehensive guide from various institutions such as

Brenner Children’s Wake Forest Baptist Health and Children’s Hospital of Atlanta (CHOA) to increase the operative management of choledocholithiasis using approachable techniques to limit need of additional imaging and procedures, as well as to promote decrease in length of stay.



Stakeholders: pediatric surgeons, patients, families

Challenges and solutions:


  • An underutilized technique
  • Perceived complexity
  • Lack of experience

Links to published data (used to develop protocol or demonstrating success of protocol): [5]

Submitted by: Jessica Ruah, MD

Additional implementers: Lucas Neff, MD

Recent Research



  1. Vaughan J, Gurusamy KS, Davidson BR. Day-surgery versus overnight stay surgery for laparoscopic cholecystectomy. Cochrane Database Syst Rev. 2013.  [PMID:23904112]
  2. Dalton BG, Gonzalez KW, Knott EM, et al. Same day discharge after laparoscopic cholecystectomy in children. J Surg Res. 2015;195(2):418-21.  [PMID:25770737]
  3. Reismann M, von Kampen M, Laupichler B, et al. Fast-track surgery in infants and children. J Pediatr Surg. 2007;42(1):234-8.  [PMID:17208572]
  4. Reismann M, Dingemann J, Wolters M, et al. Fast-track concepts in routine pediatric surgery: a prospective study in 436 infants and children. Langenbecks Arch Surg. 2009;394(3):529-33.  [PMID:19050911]
  5. Bosley ME, Gaffley MWG, Zeller KA, et al. Balloon sphincteroplasty in pediatric laparoscopic common bile duct exploration. J Pediatr Surg. 2021;56(4):825-828.  [PMID:33349422]
  6. Mohseni S, Bass GA, Forssten MP, et al. Common bile duct stones management: A network meta-analysis. J Trauma Acute Care Surg. 2022;93(5):e155-e165.  [PMID:35939370]
  7. Overman RE, Hsieh LB, Thomas TT, et al. Pediatric Laparoscopic Common Bile Duct Exploration: An Opportunity to Decrease ERCP Complications. J Surg Res. 2019;242:318-322.  [PMID:31129240]
  8. Rancan A, Andreetta M, Gaio P, et al. "Rendezvous" Procedure in Children with Cholecysto-Choledocholithiasis. J Laparoendosc Adv Surg Tech A. 2019;29(8):1081-1084.  [PMID:31237499]
Last updated: May 5, 2023