Incomplete excision of the gallbladder during laparoscopic cholecystectomy

Residual gall bladder: An emerging disease after safe cholecystectomy

Backgrounds/Aims

Residual gallbladder mucosa left after subtotal/partial cholecystectomy is prone to develop recurrent lithiasis and become symptomatic, which mandates surgical removal.

Methods

We retrospectively evaluated the patients with residual gallbladder referred to us from January 2011 to December 2017. Based on MRCP we classified calot's anatomy to – type I where cystic duct was seen and type II where sessile GB stump was seen.

Results

21 patients with median age 38 years and M:F::1:9.5, had undergone cholecystectomy (3 months-20 years) prior, presented with recurrent biliary pain. 3 had jaundice (CBD stone, Mirizzi and biliary stricture), 1 had pancreatitis and one had malignancy of the GB. Imaging revealed type I anatomy in 14 (67%) and type II in 7 (33%). All underwent completion cholecystectomy – open in 18 and laparoscopic in 3 (one converted to open). Additional procedure was required in 5 patients – CBD exploration in 2 (10%) and one each Hepatico-jejunostomy, extended cholecystectomy and splenectomy. Median hospital stay was 1 day. There was no mortality and 10% morbidity. One patient with malignancy died at 2 years, two died of unrelated cause, one developed incisional hernia and the remaining were well at a median follow up of 29 months.

Conclusions

Residual GB lithiasis should be suspected if there are recurrent symptoms after cholecystectomy. MRCP based proposed classification can guide the management strategy. Completion cholecystectomy is curative.

Surgical Management of Cystic Duct Stump Stone or Gall Bladder Remnant Stone

Retained calculi in the cystic duct or gall bladder remnant can present as a post-cholecystectomy problem. Increased suspicion is necessary to diagnose this condition in a symptomatic post-cholecystectomy patient. Ultrasonography usually detects this condition, but magnetic resonance cholangiopancreatography is the test of choice for diagnosis as well as for surgical planning. Laparoscopic re-excision of the stump in most cases is feasible and safe. It is increasingly becoming the treatment of choice.

Management of residual gall bladder: A 15-year experience from a north Indian tertiary care centre

Backgrounds/Aims

A residual gallbladder (RGB) following a partial/subtotal cholecystectomy may cause symptoms that require its removal. We present our large study regarding the problem of a RGB over a 15 year period.

Methods

This study involved a retrospective analysis of patients managed for symptomatic RGB from January 2000 to December 2015.

Results

A RGB was observed in 93 patients, who had a median age of 45 (25-70) years, and were comprised of 69 (74.2%) females. The most common presentation was recurrence pain (n=64, 68.8%). Associated choledocholithiasis was present in 23 patients (24.7%). An ultrasonography (USG) failed to diagnose RGB calculi in 10 (11%) patients; whereas, magnetic resonance cholangio-pancreatography (MRCP) accurately diagnosed RGB calculi in all the cases except for 2 (4%) and, additionally, detected common bile duct (CBD) stones in 12 patients. Completion cholecystectomy was performed in all patients (open 45 [48.4%]; laparoscopic 48 [51.6%] and 19 [20.4%] patients required a conversion to open). The RGB pathology included stones in 90 (96.8%), Mirizzi's syndrome in 10 (10.8%) and an internal fistula in 9 (9.7%) patients. Additional procedures included CBD exploration (n=6); Choledocho-duodenostomy (n=4) and Roux-en-Y hepatico-jejunostomy (n=3). The mortality and morbidity were nil and 11% (all wound infection), respectively. Two patients developed incisional hernia during follow up. The mean follow up duration was 23.1 months (3-108) in 65 patients and the outcome was excellent and good in 97% of the patients.

Conclusions

Post-cholecystectomy recurrent biliary colic should raise suspicion of RGB. MRCP is a useful investigation for the diagnosis and assessment of any associated problems and provides a roadmap for surgery. Laparoscopic completion cholecystectomy is feasible, but is technically difficult and has a high conversion rate.

Performing the Difficult Cholecystectomy Using Combined Endoscopic and Robotic Techniques: How I Do It

Laparoscopic cholecystectomy is the standard of care for cholelithiasis as well as cholecystitis. However, in the setting of Mirizzi syndrome or gangrenous cholecystitis where the critical view cannot be ascertained, subtotal cholecystectomy may be necessary. Using the robot-assisted approach, difficult cholecystectomies can be performed upfront without need for partial cholecystectomy. Even in the setting of Mirizzi syndrome where severe scarring and fibrosis are evident, definitive cholecystectomy and takedown of the cholechystocholedochal fistula can be performed in a safe and feasible fashion following successful endoscopic common bile duct stent placement. The purposes of this report are to review the history of Mirizzi syndrome as well as its traditional and novel treatment techniques and highlight technical pearls of the robotic approach to this diagnosis.

Residual gallbladder stones after cholecystectomy: A literature review

BACKGROUND

Incomplete gallbladder removal following open and laparoscopic techniques leads to residual gallbladder stones. The commonest presentation is abdominal pain, dyspepsia and jaundice. We reviewed the literature to report diagnostic modalities, management options and outcomes in patients with residual gallbladder stones after cholecystectomy.

MATERIALS AND METHODS

Medline, Google and Cochrane library between 1993 and 2013 were reviewed using search terms residual gallstones, post-cholecystectomy syndrome, retained gallbladder stones, gallbladder remnant, cystic duct remnant and subtotal cholecystectomy. Bibliographical references from selected articles were also analyzed. The parameters that were assessed include demographics, time of detection, clinical presentation, mode of diagnosis, nature of intervention, site of stone, surgical findings, procedure performed, complete stone clearance, sequelae and follow-up.

RESULTS

Out of 83 articles that were retrieved between 1993 and 2013, 22 met the inclusion criteria. In most series, primary diagnosis was established by ultrasound/computed tomography scan. Localization of calculi and delineation of biliary tract was performed using magnetic resonance imaging/magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography. In few series, diagnosis was established by endoscopic ultrasound, intraoperative cholangiogram and percutaneous transhepatic cholangiography. Laparoscopic surgery, endoscopic techniques and open surgery were the most common treatment modalities. The most common sites of residual gallstones were gallbladder remnant, cystic duct remnant and common bile duct.

CONCLUSION

Residual gallbladder stones following incomplete gallbladder removal is an important sequelae after cholecystectomy. Completion cholecystectomy (open or laparoscopic) is the most common treatment modality reported in the literature for the management of residual gallbladder stones.

Laparoscopic completion cholecystectomy: a retrospective study of 40 cases

INTRODUCTION

Throughout the world, laparoscopic cholecystectomy is a widely accepted surgical treatment for both acute and chronic cholecystitis. It provides total relief of pre-surgical symptoms in up to 85% of patients. However, about 5% of patients may experience severe episodes of upper abdominal pain similar to those that they had prior to cholecystectomy; this is known as post-cholecystectomy syndrome. Gallbladder remnant with calculi is one of the causative factors. However, there have been only a few case series related to this reported in literature to date. Herein, we present our experience with laparoscopic management of gallbladder remnant with calculi in 40 cases.

METHODS

A retrospective study of 40 cases was carried out in our institution. All patients underwent open cholecystectomy at other centres, and their cases were managed by laparoscopic completion cholecystectomy.

RESULTS

The mean operating time was 102.4 min (range, 60-120 min). The duration of hospital stay was 2-4 days. Two cases were converted to open surgery because of extensive dense adhesions. One case had minor a common bile duct injury, and another had port-site infection. There were no cases of mortality.

CONCLUSION

Gallbladder remnant containing stones may be the cause of otherwise unexplained postcholecystectomy pain. Completion cholecystectomy offers a definitive treatment for any residual gallbladder remnant and can be performed laparoscopically.

Recurrent cholecystitis and cholelithiasis in a gallbladder remnant 14 years after a converted cholecystectomy

A 52-year-old man presented to the emergency department with a one-day history of epigastric pain. The patient reported a remote history of a "difficult" laparoscopic cholecystectomy that was converted to an open cholecystectomy in 1994. Further operative details were unavailable. Multiple radiologic studies were obtained, all demonstrating a saccular cystic structure in the gallbladder fossa containing calculi. A completion open cholecystectomy, or "recholecystectomy," revealed a remnant gallbladder with cholecystitis and cholelithiasis. Multimodality imaging findings are reviewed.

Laparoscopic treatment of stone recurrence in a gallbladder remnant: report of an additional case and literature review

Cholecystectomy is an effective treatment of gallstones. Nevertheless, recurrence of biliary symptoms following cholecystectomy, either laparotomic or laparoscopic, is quite common. Causes are either biliary or extrabiliary. Symptoms of biliary origin chiefly depend on bile duct residual stones or strictures. Rarely, they depend on stone recurrence in a gallbladder remnant. Diagnosis of gallstone recurrence in gallbladder remnant is difficult, mainly arising from ultrasonography, computed tomography, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography.Incomplete gallbladder removal may be either voluntary or inadvertent: in the first case, it is performed to remove gallstones without dissecting a difficult Calot's triangle or an excessively bleeding posterior wall of gallbladder caused by liver cirrhosis. Available data do not support the hypothesis that laparoscopic cholecystectomy entails an increased incidence of this condition, in spite of some opposite opinions. Treatment of lithiasis in gallbladder remnants is chiefly surgical. Although technically demanding, completion cholecystectomy can be safely performed in a laparoscopic way. We report a case of stone relapse in a gallbladder remnant, discovered 16 years following laparoscopic cholecystectomy and successfully treated by laparoscopic completion cholecystectomy. We furthermore review literature data in order to ascertain whether recent large diffusion of laparoscopic surgery causes an increase of such cases.

Stump Resections Resulting from Incomplete Operations

Stump viscera caused by an incomplete operation can present the same symptoms as before the first operation. Furthermore, as an acute clinical event, these incomplete resections may sometimes cause acute abdomen and may need emergency surgical intervention. A 34-year-old woman with a history of laparoscopic cholecystectomy 5 days before was admitted with acute abdominal symptoms. Abdominal exploration revealed that she had undergone incomplete resection of the gallbladder. Another patient, a 21-year-old man, was admitted with complaints of fluid drainage from his appendectomy incision scar. He was diagnosed as having enterocutaneous fistula. Abdominal exploration revealed a stump appendix fistulizing to the abdominal wall. The third patient was a 32-year-old man with an appendectomy scar who was admitted with complaints of acute appendicitis. The patient was diagnosed as having acute appendicitis and underwent an appendectomy. A stump appendix was removed during the operation. Surgeons should be aware of stump pathologies and keep in mind a possible incomplete operation to prevent delayed diagnosis and treatment.

Retained gallbladder/cystic duct remnant calculi as a cause of postcholecystectomy pain

BACKGROUND

Pain following cholecystectomy can pose a diagnostic and therapeutic dilemma. We reviewed our experience with calculi retained in gallbladder and cystic duct remnants that present with recurrent biliary symptoms.

METHODS

Over the last 6 years, seven patients were referred to us for the evaluation of recurrent biliary colic or jaundice. There were four men and three women ranging in age from 35 to 70 years. All seven had biliary pain similar to the symptoms that precede cholecystectomy; two of them also had also associated jaundice and one had pancreatitis. The time from cholecystectomy to onset of symptoms ranged from 14 months to 20 years (median, 8.5 Years). Four had undergone laparoscopic cholecystectomy and three had had an open cholecystectomy; none had an operative cholangiogram.

RESULTS

Five of seven underwent diagnostic endoscopic retrograde cholangiography (ERC), which revealed obvious filling defects in the cystic duct or gallbladder remnant. The final patient was diagnosed by laparoscopic ultrasound after eight negative radiographic studies. Four patients underwent laparotomy and resection of a retained gallbladder and/or cystic duct. Two patients were treated with extracorporeal shock-wave lithotripsy (ESWL); one of them also required endoscopic biliary holmium laser lithotripsy. One patient underwent successful repeat laparoscopic cholecystectomy. There were no treatment-related complications. At a median follow-up of 11.5 months, all have achieved complete stone clearance and are asymptomatic.

CONCLUSION

Retained gallbladder and cystic duct calculi can be a source of recurrent biliary pain, and a heightened suspicion may be required to make the diagnosis. This entity can be prevented by accurate identification of the gallbladder-cystic duct junction at cholecystectomy and by routine use of cholangiography. A variety of therapeutic options can be employed to obtain a successful outcome.

A stone in a grossly dilated cystic duct stump: a rare cause of postcholecystectomy pain

We describe the unusual case of a patient who developed recurrent right upper quadrant pain 25 yr after cholecystectomy. A cystic lesion containing a calculus was identified on transabdominal ultrasound, initially suggesting the possibility of gallbladder duplication. Endoscopic retrograde cholangiography identified this lesion as a massively dilated cystic duct stump. Surgical resection led to complete resolution of symptoms. Recurrent cholelithiasis involving the cystic duct stump may lead to massive dilatation, and must be considered in the differential diagnosis of postcholecystectomy syndrome.

Trends in bile duct injuries from laparoscopic cholecystectomy

Bile duct injuries are a serious complication of cholecystectomy. Laparoscopic cholecystectomies (LC) were originally associated with an increased incidence of injuries. Patients referred to a tertiary center were reviewed to assess the trends in the number, presentation, and management. Seventy-three patients were referred over a 6-year period with a maximum of 17 patients referred in 1992, but the number has not declined substantially over time. The persistent number of referrals is a consequence of ongoing injuries. One third of injuries were diagnosed at LC, and the use of cholangiography has not increased. The number of cystic duct leaks has not decreased and they represent 25% of all cases. The level of injury has remained unchanged with Bismuth types I and II in 37% and types III and IV in 38%. Excluding patients with cystic duct leaks, 58% were referred after a failed ductal repair. Definitive treatment with biliary stenting was successful in 37%, and 34 patients (47%) required a biliary-enteric anastomosis. Complications occurred in 18 patients (25%) including seven with postoperative stricture or cholangitis. No biliary reoperations have been performed at a mean follow-up of 36 months.