Gallstone extraction from a back abscess resulting from spilled gallstones during laparoscopic cholecystectomy: a case report

Lost gallstones during laparoscopic cholecystectomy as a common but underestimated complication-case report and review of the literature

Introduction

Laparoscopic cholecystectomy (LC) represents one of the most commonly performed routine abdominal surgeries. Nevertheless, besides bile duct injury, problems caused by lost gallstones represent a heavily underestimated and underreported possible late complication after LC.

Methods

Case report of a Clavien-Dindo IVb complication after supposedly straightforward LC and review of all published case reports on complications from lost gallstones from 2000-2022.

Case Report

An 86-year-old patient developed a perihepatic abscess due to lost gallstones 6 months after LC. The patient had to undergo open surgery to successfully drain the abscess. Reactive pleural effusion needed additional drainage. Postoperative ICU stay was 13 days. The patient was finally discharged after 33 days on a geriatric remobilization ward and died 12 months later due to acute cardiac decompensation.

Conclusion

Intraabdominal abscess formation due to spilled gallstones may present years after LC as a late complication. Surgical management in order to completely evacuate the abscess and remove all spilled gallstones may be required, which could be associated with high morbidity and mortality, especially in elderly patients. Regarding the overt underreporting of gallstone spillage in case of postoperative gallstone-related complications, focus need be put on precise reporting of even apparently innocuous complications during LC.

Practices and Attitudes of Surgeons With Regard to Spilled Gallstones During Laparoscopic Cholecystectomy: A Cross-Sectional Study From Saudi Arabia

BACKGROUND

Gallbladder perforation and gallstone leakage are frequent complications following laparoscopic cholecystectomy (LC). Failure to remove gallstones may result in several issues that manifest immediately or years later. The goal of this study was to evaluate the attitudes of surgeons and the procedures used by them to deal with gallstone spillage during LC.

METHODS

A cross-sectional design was followed. Surgeons in nine healthcare facilities in the Qassim region of Saudi Arabia were approached through non-probability convivence sampling and the survey was distributed in each of the general surgery divisions. The study included general surgeons who currently performed LC and incomplete responses and interns were excluded. A self-administered questionnaire was developed with 18 questions regarding demographics, center, and designation at the hospital, surgeons' experience of LC, and exposure to gallstone spillage. Furthermore, items regarding knowledge, attitude, and self-reported practices related to gallstone spillage such as incidence, complications, and intervention taken to prevent gallstone spillage were also included. The level of significance was set at P <0.05.

RESULTS

There were 82 participants of both genders, including consultants, specialists, and residents. While only 23 (28%) participants had actually observed patients with complications from spilled stones, 46 (56.1%) participants were aware of this possibility, 53 (64.6%) deemed it inappropriate to bring up gallstone spillage when securing consent for LC, and 67 (81.7%) believed that such an incident needed to be documented in the operation notes. Only 11 (13.4%) thought that the complications arising out of the unretrieved gallstones should fall under the legal purview of the operative surgeon. There were very few complications of spilled gallstones that the participants were aware of, and none of them anticipated problems to arise more than three years after LC.

CONCLUSIONS

Awareness of the risks associated with gallstone spillage during LC needs to be raised, and it is imperative to standardize the practices related to their management.

[Minimally invasive interventions for complications associated with intra-abdominal calculi after laparoscopic cholecystectomy]

OBJECTIVE

To study the possibilities of minimally invasive methods for removing intra-abdominal calculi after laparoscopic cholecystectomy.

MATERIAL AND METHODS

There were 5 patients with abdominal abscesses associated with infected calculi after previous laparoscopic cholecystectomy at the Sklifosovsky Research Institute for Emergency Care between 2020 and 2023. Mean age of patients was 55±12 years. There were 3 (60%) women and 2 (40%) men. All patients underwent minimally invasive treatment.

RESULTS

Four patients (80%) underwent percutaneous drainage of abscess with subsequent replacement by larger drains and removal of calculi with endoscopic assistance. Event-free period after cholecystectomy was 44±32 months. One patient developed subhepatic abscess in 72 months after laparoscopic cholecystectomy. This patient underwent transluminal removal of calculus through the duodenal wall. There was 1 calculus in 3 (60%) patients, 2 calculi in 1 (20%) patient and 3 calculi in 1 (20%) patient.

CONCLUSION

The above-mentioned cases demonstrate successful minimally invasive interventions for symptomatic abdominal calculi after laparoscopic cholecystectomy. Minimally invasive treatment can reduce surgical aggression and accelerate rehabilitation.

Combined Interventional Radiology and Surgical Cut-Down Approaches for Retained Gallstones

Symptomatic retained gallstones are a rare but potentially morbid condition. Post-cholecystectomy patients presenting with vague complaints or perihepatic abscesses should be considered for retained gallstones. Traditional treatment was incision and drainage or exploratory laparotomy with washout. The current standard is minimally invasive procedures. In this case report, two different and unpublished combination methods between surgery and interventional radiology were used to extract retained stones. The first patient underwent needle-wire localization pre-operatively to identify the retained stone. The surgeon cut down along the wires and excised the stone. The second patient had a 10 French drain placed to drain the abscess surrounding the stone. The surgeon cut down along the drain, as the drain's pigtail and retained stone were located in the abscess cavity. Based on this case report, we propose using the successful method of combined interventional radiology and general surgery procedures to excise larger and deeper retained dropped gallstones.

Consequences of the spilled gallstones during laparoscopic cholecystectomy: a systematic review

INTRODUCTION

Complications secondary to spilled gallstones can be classified in the category of disease of medical progress because prior to advent of laparoscopic cholecystectomy very few reports published on the topic. The aim of the present study was to investigate the predisposing factors and the complication rate of spilled gallstones during laparoscopic cholecystectomy over the past 21 years.

METHODS

Embase, Pubmed, Medline, Google scholar and Cochrane library were systematically searched for pertinent literature.

RESULTS

Seventy five out of 181 articles were selected including 85 patients; of those 38% were men and 62% women. The median age of the cohort was 64 years old and ranged between 33 and 87 years. Only 23(27%) of the authors reported the incident of spillage of the gallstones during the operation. Time of onset of symptoms varied widely from the second postoperative day to 15 years later. Ten of 85 patients were asymptomatic and diagnosed with spilled gallstones incidentally. The rest of the patients presented with complications of severe morbidity and almost, 87% of the patients needed to be treated with surgical intervention and 12% with US ± CT scan guidance drainage. Only one perioperative death reported.

CONCLUSIONS

Symptomatic patients with lost gallstones present with severe morbidity complications and required mostly major surgical procedures. Therefore, standardisation of the management of spilled gallstones is needed urgently. Hospitals need to review their policy with audits and recommendations and clinical guidelines are needed urgently.

Spilled gallstones after laparoscopic cholecystectomy: a systematic review

&lt;b&gt; Aim: &lt;/b&gt; The study was conducted to analyse the recent peer-reviewed literature related to symptomatic spilled gallstones after Laparoscopic Cholecystectomy (LC). &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Materials and methods:&lt;/b&gt; Articles published in the peer-reviewed journals of repute from 20122022 were evaluated for nine variables including: [I] age of the patient, [II] gender, [III] interval since index LC, [IV] index LC if emergent/difficult or elective/straightforward, [V] clinical presentation, [VI] spilled gallstones if detected by imaging, [VII] management, [VIII] approach to management, [IX] number of spilled gallstones. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Results:&lt;/b&gt; There were a total of 71 cases (37 males and 34 females) with a mean age of 63.7 years. The time of onset of symptoms from spilled gallstones, after index LC, ranged from 2 days to 15 years and 57 patients (80.3%) presented within 6 years. Forty (56.3%) patients were unaware of the fact that gallstone spillage had occurred during index LC. The retained gallstones were detected by imaging in 47 (66.1%) cases and they were multiple in 51 (71.8%). In 52 patients (73.2%), the stones manifested as abdominal abscess/foreign body granuloma; the other presentations being pelvic pain/fistula, intestinal obstruction, abdominal lump simulating malignancy, incidental finding of metastatic lesions and generalized peritonitis. The major approaches adopted to retrieve the retained stones included open surgery, laparoscopy and percutaneous drainage. There were two deaths (2.9%) due to spilled gallstones. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Conclusion:&lt;/b&gt; Retained gallstones represent a complication of laparoscopic cholecystectomy (LC) that has a potential to create morbidity and diagnostic difficulties, even after a substantial delay. There is a need to spread awareness about the adverse effects of spilled stones so that they are actively looked for and retrieved if gallbladder perforates during cholecystectomy. Whenever such a complication occurs, the patient should be properly informed and the details should be very clearly mentioned in the operation notes.