The fate of the dropped gallstones during laparoscopic cholecystectomy

Comparative analysis of reliability and clinical effects of the critical view of safety approach used in laparoscopic cholecystectomy in the pediatric population

PURPOSE

With the increase in indications for cholecystectomy in children, the frequency of laparoscopic cholecystectomy procedures and related problems has increased. The Critical View of Safety (CVS) is the target-specific method for identifying the cystic duct during laparoscopic cholecystectomy to prevent common bile duct injury. We hypothesize that the use of CVS is reliable in the pediatric population.

METHODS

Data of 91 patients under 18 years of age who underwent elective laparoscopic cholecystectomy were retrospectively analyzed. Patients were divided into two groups depending on whether CVS was applied. The descriptive characteristics and complications of the two groups were compared.

RESULTS

CVS was applied to 41 patients. When the groups were compared in terms of operation time, postoperative length of stay, idiopathic gallbladder perforation, dropping stone, and presence of surgical site infection, no statistical significant difference was found. However, the time to start oral feeding was shorter in CVS group (p = 0.01).

CONCLUSION

We believe CVS is a reliable method to ensure safe cystic channel identification in the pediatric population. New studies are warranted on the effectiveness of CVS for safely performing laparoscopic cholecystectomy in children, as the procedure is being performed more frequently in the pediatric population.

Spilled gallstones simulating peritoneal carcinomatosis: A case report and literature review

INTRODUCTION

Laparoscopic cholecystectomy (LC) has become the "gold standard" for the treatment of symptomatic gallstones. However, this surgical technique increases the risk of bile duct injury and lost gallstones. Since over 90% of split gallstones never become symptomatic, they often present as incidental findings on CT-scans. Careful removal of as many stones as possible, intense irrigation and suction are recommended. It has been reported that 8.5% of lost gallstones will lead to a complication, most common are abscesses.

PRESENTATION CASE

We report a case of spilled gallstones simulating peritoneal metastases on radiological investigations. Diagnosis was very difficult, not even an US-guided biopsy of the lesion was decisive. Only a diagnostic laparoscopy confirms the diagnosis.

DISCUSSION

The reaction associated with lost gallstones can mimic other causes, such as soft tissue sarcoma, malignant lymphoma or, as in our case peritoneal carcinomatosis.

CONCLUSION

Spilled gallstones are associated with uncommon, but significant complications, and even the diagnosis of such a condition can cause serious difficulties. Serious effort must be made to prevent gallbladder perforation, and accidental stone spillage should be promptly recognized and properly managed.

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.

Attitudes and Practices of Surgeons towards Spilled Gallstones during Laparoscopic Cholecystectomy: An Observational Study

The sequelae of spilled gallstones after Laparoscopic cholecystectomy (LC) and the occurring complications may go unnoticed for a long time and can be a diagnostic challenge. The aim of this survey was to study the knowledge, attitude, and practices of surgeons regarding spilled gallstones during LC. An observational, cross-sectional survey, using a questionnaire based on 11 self-answered close-ended questions, was conducted among general surgeons. Of the 138 respondents only 29.7% had observed a complication related to gallstone spillage during LC. There was varied opinion of surgeons regarding management of spilled gallstones, documenting the same in operative notes and consent. It was observed that there is lack of knowledge regarding the complications related to gallstone spillage during LC. There is need to educate surgeons regarding safe practices during LC to avoid gallstone spillage, early diagnosis, and management of complications. There is need to standardize practice to retrieve lost gallstones to reduce complication and legal consequences.

Unusual consequences of 'incomplete' laparoscopic cholecystectomy

In recent years, laparoscopic cholecystectomy (LC) has become the standard surgical practice for the treatment of cholecystolithiasis. As a recognized technical difficulty, it may be associated with the mechanical injury of the gallbladder and/or spilling some of the gallstones into the abdominal cavity. The actual incidence of the latter complication is ~10%. The removal of lost stones from the abdominal cavity is rather elaborate if not infeasible. There is little information about the behaviour of retained gallstones in the free abdominal cavity. Publications report on subsequent intraperitoneal abscesses and fistulas or on the extreme localization of the impacted gallstones. This paper presents two cases with late complications of the abandoned gallstones or gallbladder. Case 1: A 56-year-old female patient underwent an LC 7 years ago. She was recently admitted with a chronic septic condition and suspected autoimmune disease. Preoperative examinations indicated hepatic abscess. Surgery showed gallstones impacted in the gallbladder bed. Case 2: A 59-year-old male patient underwent an LC a year before his admission. His operation was followed by the development of a septic condition and a subphrenic abscess was identified. During his reoperation, a remnant gallbladder containing bile stones was found and removed. Special attention should be paid to careful revision of residual stones during LC.

Asymptomatic omental granuloma following spillage of gallstones during laparoscopic cholecystectomy protects patients and influences surgeons' decisions: a review

Spillage of gallstones in the peritoneal cavity during laparoscopic cholecystectomy (LC) occurs at rates varying from 5.7% to 16%. These gallstones often cannot be retrieved and can cause early and late abscesses at rates ranging from 0.08% to 1.4%. The case of an 86-year-old woman with colon cancer is described because during an elective right hemicolectomy a granuloma of the omentum with retained gallstones from LC performed 8 years earlier was unexpectedly found. Importantly, the gallstones were found high up in the abdominal cavity. Moreover, this report reaffirms the excellent response of the peritoneal cavity defence mechanisms for protecting patients against gallstones through asymptomatic omental granuloma. Current data indicate that every effort should be made to retrieve spilled gallstones, but routine conversion to an open cholecystectomy is not recommended. Identifying factors that impair host defence mechanisms should help surgeons' decision-making.

Abdominal abscess due to retained gallstones 5 years after laparoscopic cholecystectomy

A 76-year-old female patient with diabetes presented with pyrexia and a recurrent painful right sided loin swelling. One year previously she had undergone radiological drainage of a large right sided loin abscess. At index presentation she was investigated both radiologically and endoscopically and a source for the abscess was not found. On this presentation, a computed tomography scan confirmed a large retroperitoneal abscess pointing through the lateral abdominal wall musculature. Surgical drainage was undertaken whereby the abscess was drained and several large gallstones extruded through the incision. The patient subsequently recuperated and the wound has healed successfully by second intention. Five years previously the patient had undergone an "uncomplicated" laparoscopic cholecystectomy. This case highlights the catastrophic late effects of dropped gallstones during laparoscopic cholecystectomy.

Subphrenic abscess secondary to Actinomycosis meyeri and Klebsiella ozaenae following laparoscopic cholecystectomy

A case is reported of a subphrenic abscess 12 months post-laparoscopic cholecystectomy in a 72-year-old male with identification of Actinomyces meyeri and the oropharyngeal commensal Klebsiella ozaenae. The first organism is exceptionally rare following laparoscopic cholecystectomy and is presumed to be a result of inadvertent gallstone spillage. The second organism has not previously been reported in a subphrenic abscess. The etiopathogenesis and management of this condition are presented.

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.

Lost gallstones in laparoscopic cholecystectomy: all possible complications

BACKGROUND

Laparoscopic cholecystectomy (LC) has been the gold standard for symptomatic gallstones for 15 years. During that time, several studies and case reports have been published which outline the possible complications of lost gallstones. The aim of this review is to categorize these complications and to evaluate the frequency and management of lost gallstones.

DATA SOURCES

A Medline search from 1987 to 2005 was performed. A total of 111 case reports and studies were found, and all reported complications were listed alphabetically. Eight studies with more than 500 LCs that reported lost gallstones and perforated gallbladder were analyzed for frequency and management of lost gallstones.

CONCLUSION

Lost gallstones have a low incidence of causing complications but have a large variety of possible postoperative problems. Every effort should be made to remove spilled gallstones to prevent further complications, but conversion is not mandatory.

Abdominal Wall Sinus: An Unusual Presentation of Spilled Gallstone

Gallbladder perforation and spillage of bile is common during laparoscopic cholecystectomy. We report a case of an abdominal wall sinus due to a spilled gallstone presenting 10 years after laparoscopic cholecystectomy.

Multilocular Flank Abscess Due to Stone Migration Following Laparoscopic Cholecystectomy with Spillage of Gallstones

We report a case of a patient who presented with a large flank abscess 18 months after laparoscopic cholecystectomy. The patient underwent repeated percutaneous drainage but the abscess recurred. Further evaluation with ultrasound revealed subcutaneous tracks from the flank leading to the abdominal cavity and suspected stones in one of the tracks. Laparoscopy revealed dense adhesions at the level of the right gutter leading to a retroperitoneal track heading over to the flank. The tracks were partially opened, debrided, and two gallstones were retrieved from one of the retroperitoneal tracks. The patient's recovery was uneventful. This case demonstrates the potential migration of dropped gallstones to extraperitoneal sites leading to infectious complications. Careful dissection of the gallbladder with an attempt not to rupture it is important in order to prevent this complication. Once rupture does occur, efforts should be made to retrieve dropped stones from the peritoneal cavity. Patients presenting with intra- or extraperitoneal abscesses following laparoscopic cholecystectomy and no obvious source of infection should be evaluated for dropped stones.

Retained abdominal gallstones during laparoscopic cholecystectomy

BACKGROUND

Although gallbladder perforation with spillage of bile and gallstones is quite common, the approach to retained gallstones in the abdomen still is controversial.

METHODS

Laparoscopic cholecystectomy (LC) was performed on 580 patients with gallstones. In 101 (17%) patients, gallbladder perforations occurred during surgery, and in 43 (7%) patients, stone(s) were spilled into the peritoneal cavity. In 24 (4%) patients, gallstone(s) were not cleared entirely from the peritoneal cavity. These patients were invited to return for physical examination and biochemical tests. To investigate the retained abdominal gallstone(s) computed tomography was performed.

RESULTS

Twenty-two patients were investigated. After a median follow-up period of 121 months, retained abdominal gallstone(s) were shown in 2 patients by computed tomography. Biochemical tests were normal except in 1 patient with chronic hepatitis. All of the patients were happy with their surgical results.

CONCLUSIONS

This study revealed no harm caused by retained abdominal gallstone(s) during LC after long-term follow-up evaluation.

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.

Spilled gall stones during laparoscopic cholecystectomy: a review of the literature

Laparoscopic cholecystectomy is associated with spillage of gall stones in 5%-40% of procedures, but complications occur very rarely. There are, however, isolated case reports describing a range of complications occurring both at a distance from and near to the subhepatic area. This review looks into the various modes of presentation, ways to minimise spillage, treating the complications, and the legal implications.

Sonographic features of intra-abdominal abscess caused by spilled stones during laparoscopic cholecystectomy

Spillage of stones into the abdominal cavity resulting from perforation of the gallbladder is one of the common complications of laparoscopic cholecystectomy. Although many surgeons know that stones left in the abdominal cavity can cause late visceral abscess requiring surgical treatment, the sonographic features of such abscesses have not yet to be thoroughly investigated. We investigated the sonographic features of intra-abdominal abscesses caused by spilled stones after laparoscopic cholecystectomy using Hitachi Model EUB-525 (3.5 MHz) and Aloka Model SSD-5500 (3.75 MHz) ultrasound systems. Two thousand thirty-six laparoscopic cholecystectomy procedures were carried out at this institution from 1990 through 2001. During this period, we encountered seven cases of intra-abdominal abscess. Three of these cases were symptomatic, but abscess, granulation, or both, were found incidentally by ultrasonography in the other four patients during routine annual health examinations. Laparotomy and open drainage of pus and gallstones from the intra-abdominal abscess were necessary in five cases. Ultrasonography revealed a mass in six of the seven patients. The abscesses were located in either the right subphrenic or subhepatic space on the surface of the liver and were sometimes difficult to distinguish from liver tumors. Ultrasound showed the abscesses as oval, low-echoic, solid masses with posterior enhancement. They ranged from 20 to 58 mm in diameter, had clear margins and highly echoic peripheral rims, and showed lateral shadowing. The lesions also contained several highly echoic spots with acoustic shadows that were thought to be the spilled stones. We conclude that visceral abscess should be considered after laparoscopic cholecystectomy, and that careful observation using ultrasonography is required, especially when the gallbladder is perforated and bile and stones have spilled out.

Dropped gallstones post laparoscopic cholecystectomy mimicking peritoneal seeding: CT and ultrasound features

PURPOSE

The purpose of this work was to investigate the ultrasound (US) and CT features of dropped gallstones mimicking peritoneal seeding in patients after laparoscopic cholecystectomy (LCC).

METHOD

We describe the US and CT features of dropped gallstones mimicking peritoneal seeding in eight patients who underwent LCC. We also conducted a retrospective study of consecutive LCC patients who subsequently had CT to determine the prevalence of this condition.

RESULTS AND CONCLUSION

The density of dropped gallstones on CT ranged from hypodense to partially or completely calcified nodules. Some stones did not have visible surrounding reaction, whereas others showed an enhancing halo. All stones were echogenic and demonstrated shadowing on US. The stones were located mostly on the right side of the abdomen, and the majority were around the liver. The prevalence of dropped gallstones post laparoscopic cholecystectomy was 4.2%.

Effect of timing of surgery, type of inflammation, and sex on outcome of laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND AND PURPOSE

Studies have shown the safety and effectiveness of laparoscopic cholecystectomy (LC) for acute cholecystitis (AC). Our aim was to establish the outcome of LC in patients with AC on the basis of duration of the attack before surgery took place, the type of gallbladder inflammation, and patient sex.

PATIENTS AND METHODS

All 204 patients at Princess Basma Teaching Hospital who underwent LC for AC by the authors between September 1994 and June 1999, were retrospectively reviewed. They were categorized into Group I, where surgery took place within 72 hours of the acute attack (N = 78; 54 women and 24 men), and Group II, if later than that (N = 126; 70 women and 56 men). Gallbladder pathology was classified as gangrenous, empyema, edematous, mucocele, or AC along with contracted fibrosed gallbladder.

RESULTS

Conversion to open cholecystectomy was needed in 12% of the total series. In Group I, 3.8% of the patients needed conversion compared with 16.7% in Group II patients (P = 0.01). Also, 4% of the female patients needed conversion compared with 24% of the male patients (P = 0.000). There was an association between the pathological type of AC and the likelihood of conversion (P = 0.002), conversion being least common in those with mucocele and most common in those with empyema and gangrene. The median operation time was 75 +/- 36 minutes, but the operation time for Group II patients was significantly longer (P = 0.001) than in Group I patients. Operation time in the male patients was significantly longer than in the female patients (P = 0.000). There was no statistically significant difference in the duration of hospital stay in the two groups or in men and women. There were no deaths or main bile duct injuries in the series. In successful LC, missed stones occurred in 3.3% of the patients. Bile collection, which was treated by open surgery, developed in one female patient.

CONCLUSION

Laparoscopic cholecystectomy is a reliable and safe modality for the management of AC. It was not associated with an increased incidence of bile duct injury in this series. It should be the first choice before resorting to open surgery. Factors associated with increased conversion include delay in surgery of more than 3 days from the acute attack and certain pathology, with conversion being more likely in empyema. Conversion also was more likely in male patients.

Postoperative fistula of the abdominal wall after laparascopic cholecystectomy due to lost gallstones

Abdominal fistula caused by cholesterol gallstones, which remained in the abdominal wall after laparascopic cholecystectomy: a laparascopic cholecystectomy was performed in a 60-years-old man who was diagnosed as acute necrosing cholecystitis due to cholecystolithiasis. After removal of the gallbladder using an Endocath some gallstones remained in the excision channel of the abdominal wall. Therefore, a fistula developed in the excision channel postoperatively. As the wound healing was disturbed an investigation of the abdominal wall was performed by ultrasound. In the former excision channel several small, oval, formations with high echogenicity and faint ultrasound shadows were detected, corresponding to additional gallstones. After excision of granulation tissue and removal of the cholesterol stones, complete healing of the fistula in the abdominal wall was achieved.

The vesical granuloma: rare and late complication of laparoscopic cholecystectomy

The spillage of gallstones into the peritoneal cavity from iatrogenic perforation of the gallbladder that occurs during laparoscopic cholecystectomy can result in late and serious complications. We report a case of vesical granuloma with symptoms of dysuria, pollakiuria, and vesical tenesmus that occurred 23 months after a laparoscopic cholecystectomy. Preoperative diagnostic evaluation showed a 3-cm vesical neoformation. A partial cystectomy was performed; macroscopic and histologic examination documented a central nidus of fragmented gallstones and a picture of chronic granulomatous inflammation. Although complications related to unretrieved gallstones that spill into the peritoneal cavity during laparoscopic cholecystectomy are rare, they are being reported with increasing frequency. Therefore, it is important to use tools and techniques that prevent lacerations of the gallbladder and involve retrieval of spilled gallstones.

Laparoscopic cholecystectomy for gallstones: a comparison of outcome between acute and chronic cholecystitis

BACKGROUND

Laparoscopic cholecystectomy (LC) is now a common method of treating symptomatic gallstones, and it is increasingly being requested by the informed general public. Our aim was to evaluate the role of LC for cholelithiasis and to establish its outcome and the effect of gender on the results.

PATIENTS AND METHODS

Between September 1994 and June 1999, all patients who underwent LC for cholelithiasis were retrospectively reviewed. They were classified as having acute or chronic cholecystitis (AC or CC).

RESULTS

There were 791 patients with CC (633 females, 158 males) and 204 patients with AC (124 females, 80 males). Conversion to open cholecystectomy was needed in 0.76% and 11.8% of the patients with CC and AC, respectively (P<0.00). Four percent of the female patients with AC needed conversion as compared to 23.8% in the males (P<0.00). The low conversion rate in CC limited gender comparison. Median operation time in the patients with CC was 53+/-16 minutes as compared to 74.5+/-35.7 minutes in those with AC (P<0.00). Operation time in the male patients with CC and AC was significantly higher than in the female patients, even after excluding the converted cases (P<0.00). Median postoperative stay for patients with CC was 1.33+/-0.9 days as compared to 1.9+/-1.34 days in patients with AC (P<0.00). No statistical significance in the hospital stay was found between males and females (in CC and AC). There was no mortality in the series. There were three bile duct injuries in the patients with CC. In patients with successful LC, gallbladder perforation occurred in 18% and 31% of CC and AC patients, respectively (P<0.003). Missed stones occurred in 1.4% and 3.3% of the patients with successful LC for CC and AC, respectively. Bile collection, which was treated with open drainage, occurred in four patients with CC and one patient with AC.

CONCLUSION

LC for symptomatic cholelithiasis is safe and feasible; it should be the first choice before resorting to open surgery. In patients with AC as compared to CC, there is an increased conversion rate, longer operation time, longer hospital stay, and higher incidence of gallbladder perforation without an increase in the incidence of bile duct injuries (BDI). Male patients have a longer operation time and higher conversion rate than female patients.

Spontaneous Hepatic Hemorrhage Secondary to Retained Intraperitoneal Gallstones

We describe the first reported case of spontaneous hepatic hemorrhage as a result of retained gallstones in the region of Morison's pouch eroding into the liver parenchyma. The patient presented with acute right upper quadrant abdominal pain 7 months after laparoscopic cholecystectomy. She sustained an episode of limited spontaneous hepatic hemorrhage as noted by abdominal sonography, computerized tomography, and a 4-g/dL hemoglobin drop. Laparoscopic exploration revealed the source of hemorrhage to be an inflammatory source created by retained intraperitoneal gallstones.

Update on laparoscopic cholecystectomy, including a clinical pathway

Laparoscopic cholecystectomy is a minimally invasive procedure in which the gallbladder is removed. Patients with symptomatic gallstones or biliary dyskinesis are eligible for this procedure. No specific contraindications exist except for poor surgical risk factors. The rate of conversion to an open technique is increased in patients with acute disease, pancreatitis, bleeding disorders, unusual anatomy, and prior upper abdominal surgery. Complications occur even with experienced laparoscopists, and the important technical aspects of surgery have been identified. The length of the hospital stay and postoperative recovery time is markedly shortened compared with that of standard cholecystectomy. This procedure offers sufficient advantages to patients that it has become the standard of practice in most cases.