Dropped gallstones during laparoscopic cholecystectomy: the consequences

What's new in the hot gallbladder: the evolving radiologic diagnosis and management of acute cholecystitis

Acute cholecystitis (AC) is a common condition and its incidence is rising. New technologies have advanced the imaging diagnosis of AC, providing more structural and functional information as well as allowing the radiologist to distinguish AC from mimics and identify complications from both the disease and its management. Dual energy CT aids in detecting gallstones and gallbladder wall enhancement, which helps to diagnose AC and identify its complications. Similarly, contrast-enhanced and non-contrast perfusion ultrasound techniques improve detection of abnormal gallbladder wall enhancement. Advances in MR imaging including hepatobiliary contrast agents aid in characterizing post-cholecystectomy complications such as bile leaks. Newer interventional techniques have also expanded the suite of options for minimally invasive management. Lumen apposing metal stents provide more options for conservative treatment in non-surgical candidates and are compared to a standard percutaneous cholecystostomy. Radiologists should be familiar with these advanced imaging methods and intervention techniques and the value they can bring to the diagnosis and management of AC.

"Target sign" from dropped gallstones after laparoscopic cholecystectomy

Isolated case reports and small series in radiologic and surgical literature relay the different modes of clinical presentation that arise secondary to spillage of gallstones during surgery. We report a case of a 70-year-old female who presented with a 2-week history of right-sided abdominal pain. CT (computerized tomography) imaging findings demonstrated multiple peripherally enhancing hypoattenuating lesions in the right subphrenic space abutting the hepatic dome, concerning for abscesses. The lesions were found to have a characteristic central hyperattenuating focus (Target Sign) consistent with gallstones, as identified on a pre-cholecystectomy CT, resulting in the early diagnosis and treatment of dropped gallstones from prior laparoscopic cholecystectomy approximately 1 year prior to presentation.

Infected Renal Cyst as a Complication of Dropped Gallstones during Laparoscopic Cholecystectomy

Dropped gallstones are a relatively common complication, occurring in 3% to 32% of laparoscopic cholecystectomies performed, depending on various intraoperative risk factors. However, complications arising from dropped gallstones are relatively rare, occurring in fewer than 1% of such patients, and can include abscesses and inflammatory masses confined to the subhepatic space, presenting days to years later. We report a patient who developed an infected renal cyst as a result of dropped gallstones, which created a fistula from the duodenum to a previously simple right renal cyst, which was initially identified on an abdominal CT scan. Dropped gallstones can result in substantial morbidity in a minority of patients following cholecystectomy performed for cholecystitis, and a high clinical as well as radiological index of suspicion may be required for accurate early recognition and treatment.

Consequences of Lost Gallstones During Laparoscopic Cholecystectomy: A Review Article

BACKGROUND

Laparoscopic cholecystectomy (LC) has become a popular and widespread procedure for the treatment of gallstone disease. There is still an increasing concern about specific complications of LC due to gallbladder perforation and spillage of bile and stones. Although unretrieved intraperitoneal gallstones rarely become symptomatic, their infective complications may cause serious morbidities even after a long interval from LC.

METHODS

We performed a review of the literature on the diagnosis, prevention, consequences, and management of lost gallstones. All studies with a focus on lost gallstones or perforated gallbladder were analyzed to evaluate the postoperative complications.

RESULTS

Between 1991 and 2015, >250 cases of postoperative complications of spilled gallstones were reviewed in the surgical literature. The most common complications are intraperitoneal abscesses and fistulas. Confusing clinical pictures due to gallstones spreading in different locations makes diagnosis challenging. Even asymptomatic dropped gallstones may masquerade intraperitoneal neoplastic lesions.

CONCLUSIONS

Every effort should be made to prevent gallbladder perforation; otherwise, they should be retrieved immediately during laparoscopy. In cases with multiple large spilled stones or infected bile, conversion to open surgery can be considered. Documentation in operative notes and awareness of patients about lost gallstones are mandatory to early recognition and treatment of any complications.

Intraluminal Bowel Erosion: A Rare Complication of Retained Gallstones after Cholecystectomy

Laparoscopic cholecystectomy for acute cholecystitis and cholelithiasis is one of the most common operations performed in the United States. Inadvertent perforation and spillage of gallbladder contents are not uncommon. The potential impact of subsequent retained gallstones is understated. We present the case of an intraperitoneal gallstone retained from a previous cholecystectomy eroding into the bowel and leading to intraluminal mechanical bowel obstruction requiring operative intervention. This case illustrates the potential risks of retained gallstones and reinforces the need to diligently collect any dropped stones at the time of initial operation.

Necrotizing Soft Tissue Infection Caused by Spilled Gallstones

We report a case of a 57-year-old woman who presented with a necrotizing soft tissue infection of the right anterior abdominal wall, 1 year after open cholecystectomy for gallbladder perforation. Surgical exploration revealed pigmented gallstones along with pus in the abdominal wall and gallbladder fossa. Intraoperative spillage of gallstones is common during both open and laparoscopic cholecystectomy, but, in rare cases, can lead to serious complications including necrotizing infection of the abdominal wall.

A rare late complication of laparoscopic cholecystectomy

An 86-year-old woman presented three years after laparoscopic cholecystectomy with right upper quadrant pain and raised inflammatory markers. Liver function tests were normal; however, a previous ultrasound scan suggested a common bile duct stone so she was treated for cholangitis secondary to choledocholithiasis. Repeat ultrasound scan again showed a common bile duct (CBD) stone and also a subdiaphragmatic abscess. CT scan confirmed the abscess, associated with a surgical clip from her previous surgery. There was no evidence of a persistent CBD stone on the CT scan. She was treated conservatively with intravenous antibiotics and her symptoms improved. Follow-up MRI did not show any choledocholithiasis. Surgical clips causing delayed abscess formation are very unusual. We discuss the presentation, investigations and treatment of this interesting case. Existing relevant literature is reviewed, and management strategies to treat such rare complications are suggested.

Retroperitoneal Abscess Formation as a Result of Spilled Gallstones during Laparoscopic Cholecystectomy: An Unusual Case Report

One of the complications of laparoscopic cholecystectomy for gallstone disease that seems to exceed that of the traditional open method is the gallbladder perforation and gallstone spillage. Its incidence can occur in up to 40% of patients, and in most cases its course is uneventful. However in few cases an abdominal abscess can develop, which may lead to significant morbidity. Rarely an abscess formation due to spilled and lost gallstones may occur in the retroperitoneal space. We herein report the case of a female patient who presented with clinical symptoms of sepsis six months following laparoscopic cholecystectomy. Imaging investigations revealed the presence of a retroperitoneal abscess due to retained gallstones. Due to patient's decision to refuse abscess's surgical drainage, she underwent CT-guided drainage. The 24-month followup of the patient has been uneventful, and the patient remains in good general condition.

Imaging late complications of cholecystectomy

OBJECTIVE

To review the imaging findings in late complications of cholecystectomy.

CONCLUSIONS

Late postcholecystectomy complications include papillary stenosis, choledocholithiasis, biliary stricture, remnant gallbladder, and dropped gallstones. Such complications can cause substantial morbidity, and knowledge of the imaging appearances can facilitate expeditious diagnosis and treatment.

The last place you would expect to find a gallstone

The increasing use of laparoscopic cholecystectomy has led to an increased frequency of gallbladder perforation and subsequent gallstone spillage in the abdominal cavity. Occasionally unretrieved gallstones can cause infection, adhesions, and obstruction. Furthermore, spilt stones can cause erosion into adjacent organs and can migrate to distant sites, causing a variety of complications. We report the unusual case of a patient who presented with spontaneous erosion of gallstones through Grynfeltt's triangle, 1 year after laparoscopic cholecystectomy and review the current literature.

Multiple abdominal granuloma caused by spilled gallstones with imaging findings that mimic malignancy

Multiple abdominal granulomas caused by spilled gallstones during a laparoscopic cholecystectomy are a rare complication. The images of the granuloma mimicked malignancy.

Laparoscopic Common Bile Duct Exploration: Our First 50 Cases

Introduction: Laparoscopic common bile duct exploration (CBDE) is becoming more popular in the management of choledocholithiasis due to improved laparoscopic expertise and advancement in endoscopic technology and equipment. This study aimed to evaluate the safety and short-term outcome of laparoscopic CBDE in a single institution over a 3-year period. Materials and Methods: A retrospective review of the records of all patients who underwent laparoscopic CBDE in Tan Tock Seng Hospital between January 2006 and September 2008 was conducted. Results: Fifty consecutive patients, with a median age of 60 years (range, 27 to 85) underwent laparoscopic CBDE for choledocholithiasis during the study period. About half of our patients presented as an emergency with acute cholangitis (32.0%) accounting for the majority. A total of 22 (44.0%) patients underwent laparoscopic CBDE as their primary procedure while the remaining 28 (56.0%) were subjected to preoperative ERCP initially. Of the latter group, documented stone clearance was only documented in 5 (17.9%) patients. Laparoscopic CBDE via the transcystic route was performed in 27 (54.0%) patients while another 18 patients (36.0%) had laparoscopic choledochotomy and 1 patient (2.0%) had laparoscopic choledocho-duodenostomy. There were 4 (8.0%) conversions in our series. The median operative time for laparoscopic CBDE via the transcystic route and the laparoscopic choledochotomy were 170 (75-465) and 250 (160-415) minutes, respectively. For the 18 patients who underwent a laparoscopic choledochotomy, T-tube was inserted in 8 (44.4%) patients while an internal biliary stent was placed in 4 (22.2%) with the remaining 6 patients (33.3%) undergoing primary closure of the choledochotomy. The median length of hospital stay was 2 days (range, 1 to 15) with no associated mortality. The main complications (n = 4, 8.0%) included retained CBD stones and biliary leakage. These were treated successfully with postoperative endoscopic retrograde cholangiopancreatography (ERCP) with/without percutaneous drainage with no further surgery required. Conclusion: Laparoscopic CBDE is a safe operation with good outcome in managing choledocholithasis. Its dividends include the numerous benefits of minimally invasive surgery. If possible, transcystic extraction is preferred to choledochotomy, as this obviates the need for biliary diversion. ERCP will still hold an important role in certain instances in the management of choledocholithiasis. Key words: Common bile duct stones, Laparoscopy

Painless obstructive jaundice secondary to a common bile duct abscess: a delayed sequela of cholecystectomy

Complications related to cholecystectomy are well described. Most occur in the early postoperative period and are recognised either at the time of, or shortly after surgery. Clinical sequelae occurring years following cholecystectomy are rare and infrequently reported. In addition, most delayed complications are related to the continuing presence or new formation of gallstones. In this paper we present a unique case of an abscess of the common bile duct wall, presenting with painless obstructive jaundice more than 30 years following an open cholecystectomy, without the presence of gallstones. The clinical presentation, investigations, and treatment are discussed with a review of other relevant reported cases in the literature.

An unusual "hernia": losing a stone is not always a good thing!

A 42-year-old woman presented to the surgical outpatient department with what appeared to be a strangulated recurrent paraumbilical hernia. She was taken to theatre, where exploration revealed an unexpected diagnosis: an abdominal wall abscess that had formed around what appeared to be a gallstone dropped at the umbilical port site of a laparoscopic cholecystectomy performed 10 years previously. The abscess was incised and drained and a connection with the abdominal cavity excluded. The patient made a full recovery. Complications relating to spilled gallstones are rare, but can present in a variety of ways and sometimes many years after the original surgery. They should always be considered in a patient with a history of cholecystectomy presenting with an abdominal wall mass. There is no clear evidence of the best imaging modalities to be used for investigation. Methods for reducing the risk of such complications and the principles of different treatments are discussed.

The impact of gallbladder aspiration during elective laparoscopic cholecystectomy: a prospective randomized study

BACKGROUND

The aim of this prospective randomized study was to investigate the effect of gallbladder aspiration during elective laparoscopic cholecystectomy on the operative and postoperative course of patients.

METHODS

Between August 2005 and February 2007, 160 consecutive patients with symptomatic cholelithiasis were randomized into 2 clinically comparable groups. Gallbladders were aspirated before dissection in group A (aspiration, n = 80), and they were not aspirated in group C (control, n = 80). Patients' characteristics and general operative outcomes were compared and analyzed.

RESULTS

The mean dissection time (P = .45), amount of gas used (P = .49), and liver bed bleeding (P = .30) were not significantly different between group A and group C. Similarly, there were no differences between the groups regarding gallbladder perforation (P = .12), spillage of gallstones into the abdominal cavity (P = 1.00), or wound infection (P = 1.00).

CONCLUSIONS

The findings suggest that routine gallbladder aspiration is unnecessary in elective laparoscopic cholecystectomy.

Short-term effects of gallbladder perforations during laparoscopic cholecystectomy on respiratory mechanics and depth of pain

BACKGROUND

In this study the effects of gallbladder perforations during laparoscopic cholecystectomy on respiratory mechanics and depth of pain in the postoperative period was evaluated.

METHODS

Between April 2004 and February 2006 we planned to perform 179 laparoscopic cholecystectomies. One hundred of these patients were included in this study. Patients were divided into two groups: group 1 with gallbladder perforation during the operation and group 2 without perforation. Two groups were compared regarding age, gender, comorbidities, mean hospital stay, respiratory function tests, and postoperative pain scores.

RESULTS

Gallbladder perforation occurred in 33 patients (33%). The male-to-female ratio of group I was 5/28. In group 2 the male-to-female ratio was 12/55. Age and perforation had a significant correlation according to Spearman's correlation test (p < 0.05, r = 0.211). Regarding respiratory function tests and arterial blood gases analysis, there was a significant decrease in both groups postoperatively but perforation had no effect on them. No statistically significant difference occurred regarding mean hospital stay and postoperative visual pain scores (p > 0.05).

CONCLUSION

Gallbladder perforation during laparoscopic cholecystectomy had no effect on postoperative respiratory mechanics and depth of pain.

Dropped Gallstones and Surgical Clips After Cholecystectomy

AIM

To describe the spectrum of computed tomographic (CT) findings in patients with dropped gallstones or dropped surgical clips after cholecystectomy.

MATERIALS AND METHODS

Seventeen patients diagnosed with dropped gallstones and 26 patients with dropped surgical clips on computed tomography after cholecystectomies were included in this study. The CT scans were evaluated for the number, location, size, and density of dropped gallstones or surgical clips and for the presence of an abscess. The cases were evaluated for the outcome on clinical and/or CT follow-up.

RESULTS

The location for dropped gallstones and dropped surgical clips after cholecystectomy was the Morrison's pouch in 17 and 12 patients, respectively. There were 9 abscesses in the study, all located in the Morrison's pouch. Duration from surgery to observation of abscess on computed tomography ranged from 5 days to more than 4.7 years. None of the patients with a dropped surgical clip from cholecystectomy developed an associated abscess.

CONCLUSIONS

Subhepatic location was the most common location for dropped gallstones with associated abscess and for dropped surgical clips. Dropped cholecystectomy clips are not associated with increased risk of abscess formation and therefore do not need screening follow-up or operative removal. Abscess formation around dropped gallstone is a more common complication and requires surgical treatment in most when associated with an abscess.

Routine intraoperative aspiration of gallbladder during laparoscopic cholecystectomy

BACKGROUND

Technical modifications and methods for gallbladder dissection to minimize the risk of gallbladder perforation during laparoscopic cholecystectomy (LC) are described. The authors aimed to investigate the effects of gallbladder aspiration during LC on the operative and postoperative course of patients.

METHODS

For this study, 200 patients undergoing LC for symptomatic cholelithiasis were randomly divided into two groups. Gallbladders were aspirated before dissection in group A (n = 100), and they were not aspirated in group B (n = 100). Operative and postoperative data on the patients were collected.

RESULTS

The rate of gallbladder perforation was significantly lower in group A than in group B (p = 0.0003). The operative time was significantly shorter in group A (46.70 +/- 15.93 min) than in group B (60.75 +/- 22.09 min) (p = 0.047). Postoperative complications were more numerous in group B. The hospital stay was significantly longer in group B (1.55 +/- 0.81 days) than in group A (1.3 +/- 0.5 days; p = 0.004).

CONCLUSION

The findings demonstrate the advantages of gallbladder aspiration in elective cases.

Xanthogranulomatous Panniculitis After Spillage of Gallstones During Laparoscopic Cholecystectomy Mimics Intra-abdominal Malignancy

Spillage of gallstones into the peritoneal cavity during laparoscopic cholecystectomy (LC) occurs frequently and may be associated with complications. Most of these complications present late after the original procedure, and many have clinical pictures that are not related to biliary etiology, which can confound and delay adequate management. Our patient presented with an intra-abdominal firm heterogeneous mass lesion. Imaging studies showed obvious abdominal wall invasion, and CA-125 level was elevated. Thus, malignancy could not be excluded. Final operative pathology revealed xanthogranulomatous inflammation. Complications of LC should be considered for patients with intra-abdominal abscess or mass lesion if there is a history of LC, regardless of time interval.

Gastro Cutaneous Fistula After Laparoscopic Cholecystectomy

A young lady presented with a nonhealing epigastric sinus after 2 years of laparoscopic cholecystectomy performed outside. Upper gastrointestinal (GI) endoscopy and contrast study confirmed its communication with the stomach. At relaparoscopy, the fistula was identified, dissected, and stapled with endo-GIA stapler. Patient made an uneventful postoperative recovery and she is well after 20 months of surgery. It may be concluded that laparoscopic cholecystectomy can lead to the development of gastrocutaneous fistula that can be managed by relaparoscopy and stapling the tract with endo-GIA devices.