Is the retrieval of lost peritoneal gallstones worthwhile?

Chronic cutaneous chest wall fistula and gallstone empyema due to retained gallstones

We report a case of a 72-year-old man who presented with a persistent pleural effusion and painful abscess in the right lower chest wall 6 months following a laparoscopic cholecystectomy. The patient subsequently developed a chronic cutaneous chest wall fistula requiring a large resection and complex closure. The complication was likely secondary to intraoperative spillage of gallstones. While previous reports describe gallstone spillage in the abdominal cavity as benign, this case illustrates that stones left in the abdominal cavity can potentially lead to significant morbidity. Therefore, stones should be diligently removed from the abdominal cavity when spillage occurs. In addition, it is important that operative notes reflect the occurrence of stone spillage so stones may be suspected when a patient presents with an abdominal or thoracic infection following a cholecystectomy.

Cicatrical cecal volvulus following laparoscopic cholecystectomy

Complications can arise from spilled gallstones during cholecystectomy. A surgeon should make every effort to avoid gallbladder perforation and spillage of stones during laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is the procedure of choice for the treatment of symptomatic biliary disease. There is currently no agreement on the management of spilled gallstones, which commonly occurs during laparoscopic cholecystectomy and may produce significant morbidity. We present a case of spilled gallstones causing cicatrical cecal volvulus and also provide a review of pertinent literature.

Dropped gallstones during laparoscopic cholecystectomy: the consequences

During laparoscopic cholecystectomy, gallbladder perforation has been reported, leading to bile leak and spillage of gallstones into the peritoneum. Because the consequences can be dangerous, conversion to laparotomy as an instant management for gallstone spillage is one of the topics of current discussion in laparoscopic cholesystectomy. In this article, we discussed the option of not converting to laparotomy after intraperitoneal gallstone spillage as an acceptable approach to management or not.A prospectively maintained database of 1528 consecutive laparoscopic cholecystectomies performed during a 10-year period at the 4th Surgical Clinic of The Ankara Numune Education and Research Hospital was analyzed. Perforations resulting in gallstone spillage into the abdominal cavity were documented in 58 (3.8%) patients. Among those 58 patients seven (12%) experienced complications from retained stones. To maintain acceptable management of such patients, surgeons should inform each patient preoperatively that stones may be spilled. In the event of spillage, the patient should be informed postoperatively, and followed closely for complications. Follow-up should not waste time and money with unnecessary examinations, and it should avoid psychological trauma to the patient with a wrong diagnosis of cancer as a stone may mimic cancer radiologically. Thus the surgeon should not hesitate to record the events and inform the patient about the spillage of the stones and possible consequences.

The Effect of the Degree of Histologic Inflammation on Gallbladder Perforation During Laparoscopic Cholecystectomy

PURPOSE

Laparoscopic cholecystectomy (LC) is the gold standard operation for the treatment of symptomatic gallstones. Intraoperative gallbladder perforation is a common complication encountered during the surgery. The purpose of this study was to identify the effects of inflammation on gallbladder perforation during LC.

METHODS

Between July 1997 and March 2003, 509 patients underwent LC for symptomatic gallstone disease at the Department of Surgery at Vakif Gureba Training Hospital. Data were collected retrospectively. Patients with and without gallbladder perforation were compared in terms of gender, age, anatomic difficulty, experience of the surgeon, omental and other organ adhesions to the gallbladder, and the findings of inflammation on the resected gallbladder.

RESULTS

Intraoperative gallbladder perforation occurred in 85 patients (16.6%). Although no differences were found between the perforated and nonperforated groups regarding age, gender, and chronic inflammation on the resected gallbladder, there were significant differences in terms of acute inflammation, anatomical difficulty, experience of the surgeon, and omental and organ adhesions.

CONCLUSION

Acute inflammation, degree of anatomic difficulty, the experience of the surgeon, and omental or other organ adhesions were associated with gallbladder perforation during LC.

Peritoneal gallstones following laparoscopic cholecystectomy

BACKGROUND

Gallstone spillage during laparoscopic cholecystectomy (LC) is a common intraoperative event. Although gallstones left in the peritoneal cavity were initially considered harmless, a significant number of complications have been reported. Our aim was to quantify the likelihood, and to document the range, of subsequent complications.

METHODS

A Medline search from 1987 to January 2003 was performed. Articles with more than 500 LCs that quantified the frequency of complications due to peritoneal gallstones were reviewed, as were representative case studies of different stated complications.

RESULTS

Six studies, covering 18,280 LCs, were found. The incidence of gallbladder perforation was 18.3%, that of gallstone spillage was 7.3%, and that of unretrieved peritoneal gallstones was estimated to be 2.4%. There were 27 patients with complications. The likelihood of a complication when gallstone spillage occurred was 2.3%, which increased to 7.0% when unretrieved peritoneal gallstones were documented.

CONCLUSION

Spilt gallstones have a small but quantifiably real risk of causing a wide range of significant postoperative problems.

Transdiaphragmatic abscess: late thoracic complication of laparoscopic cholecystectomy

Spillage of gallstones into the peritoneal cavity is a frequent problem during laparoscopic cholecystectomy (as much as 30%) and is frequently dismissed as a benign occurrence. However, several complications associated with spillage of gallstones have been reported recently. Most of these complications presented late after the original procedure, many with clinical pictures not related to biliary etiology, confounding and delaying adequate management. For patients presenting with intraabdominal or thoracic abscesses of unknown etiology, if there is a history of laparoscopic cholecystectomy, regardless of the time interval, certain evaluations should be considered. A sonogram and a CT scan are advisable to detect retained extraluminal gallstones, as most patients will require, not only drainage of fluid collections, but also removal of the stones. A case is described of a patient who presented with a right empyema and transdiaphragmatic abscess 18 months after a laparoscopic cholecystectomy. Treatment included decortication, enbloc resection of the abscess, repair of the diaphragm, and drainage.

Pelvic adhesion formation after intraperitoneal installation of gallstones in a rabbit model

OBJECTIVE

To investigate whether intraperitoneal gallstones increase the risk of pelvic adhesions in a rabbit model.

DESIGN

Prospective, randomized, blinded, sham and human antigen controlled trial.

SETTING

An academic research environment.

SUBJECT(S)

Twelve New Zealand white rabbits.

INTERVENTION(S)

Twelve rabbits were divided into three groups of four each; a sham operation group, a gallstone and bile group (study group), and a human serum albumin and bile group (antigenic control). Three weeks after the operation individual subjects were randomized, with groups concealed to observers, and a necropsy was performed on each rabbit.

MAIN OUTCOME MEASUREMENT(S)

Necropsy was performed on each rabbit, and the adhesions were scored for extent, type, tenacity, inflammation, and gallstone involvement.

RESULT(S)

There was a statistically and biologically significant increase in gallstone involvement in adhesions, especially pelvic adhesions, in the study group.

CONCLUSION(S)

This study, along with an increasing number of case reports, suggests that gallstones inadvertently left in the peritoneal cavity may increase the morbidity of laparoscopic cholecystectomy. In females of reproductive age these gallstones may induce pelvic adhesions that may interfere with fertility or be associated with pelvic pain.

Lost gallstones--a small but real complication

Retained gallstones are considered a complication of cholecystectomies. If stones can be removed using minimally invasive procedures (i.e., laparoscopically), patients' recovery time may decrease and satisfaction may increase. Correct and immediate diagnosis of this complication at the time of the procedure often is the determining factor between patients' full recovery and their potential chronic illness. This article describes diagnostic tests and techniques used to surgically correct this complication and presents two case studies depicting patients' experiences from a few months to nine years postoperatively.

The spilled stone. A potential danger after laparoscopic cholecystectomy

The application of laparoscopic techniques in digestive surgery to areas in which there was no previous experience has favored the appearance of new complications and clinical situations that were not observed during the open era. Initial opinion considered that stones left in the abdominal cavity were harmless, and a few clinical and experimental studies supported this opinion. But cumulative reports of cases suggest a potential danger. From 1991 to date, 49 cases of complications related to stones left in the abdominal cavity have been reported with severe complications that required an open surgical procedure. Stone spillage has not always been considered an indication of conversion of laparoscopic cholecystectomy but is now accepted as a source of infrequent but severe complications that may require a reintervention for treatment. Therefore it is recommended that efforts should be made to retrieve all spilled stones; the surgical procedure should be prolonged until this is achieved, in order to reduce one source of unpredictable morbidity. Open retrieval should be considered in selected cases if a large number or large stones are lost.