Lost stones during laparoscopic cholecystectomy

Percutaneous Endoscopy and Image-guided Retrieval of Dropped Gallstones - A Case Series

BACKGROUND

Recurrent abscesses can happen due to dropped gallstones (DGs) after laparoscopic cholecystectomy (LC). Recognition and appropriate percutaneous endoscopy and image-guided treatment options can decrease morbidity associated with this condition.

MATERIALS AND METHODS

We report a minimally invasive endoscopy and image-guided technique for retrieval of dropped gallstones in a series of 6 patients (M/F=3/3; median age: 75.5 years [68 to 82]) presenting with recurrent or chronic intra-abdominal abscesses secondary to dropped gallstones. Technical success was defined as the visualization and retrieval of all stones. DGs were identified on pre-procedure imaging. Number of abscesses recurrence was 12 (1/6), 1 (3/6), and 0 (2/6) with a median interval of 2 months (1 to 21) between cholecystectomy and abscess development.

RESULTS

Percutaneous endoscopy and fluoroscopy guidance were utilized in all cases. Technical success was achieved in 4 patients (66%). The median procedure time was 65.8 minutes (39 to 136). The median fluoroscopy time and dose were 12.6 min (3.3 to 67) and 234 mGy (31 to 1457), respectively. There were no intraprocedure and postprocedure complications. No abscess recurrence was reported among successful procedures during a median follow-up of 193 days (51 to 308).

CONCLUSION

Percutaneous image and endoscopy-guided lithotripsy/lithectomy are safe and effective. This technique is a suitable alternative to open surgery for dropped gallstones.

LEVEL OF EVIDENCE

Level 4, Case Series.

Chronic abdominal wall sinus secondary to missed spilled gallstones in laparoscopic cholecystectomy: a harrowing experience

Gallbladder perforation with spillage of gallstones is not uncommon during laparoscopic cholecystectomy. Stone spillage can cause several complications. We report a case of recurrent discharging sinuses on the right back 4 years after laparoscopic cholecystectomy in a 44-year-old female patients. She suffered for 9 years to undergo empirical treatment for suspected tuberculosis, including repeated attempts at sinus tract excision done at different hospitals. We did a computed tomography sinogram, which revealed the tract extending from the right flank into a cavity in the right subpleural space. We proceeded with the sinus tract excision which extended between the tips of the 10th and 11th ribs, spreading to the right subpleural space where pus mixed with multiple gall stones were retrieved. Spilled stones may result in complications, making diagnosis difficult and seriously harming the patient physically, mentally, and economically. The need for accurate documentation and patient knowledge of missing gallstones cannot be understated.

Do not get stumped: multimodality imaging findings of early and late post-cholecystectomy complications

Cholecystectomy is the most performed intra-abdominal surgical procedure in the US, with 1.2 million performed annually, and is predominantly performed laparoscopically. Although largely safe, laparoscopic cholecystectomy results in higher rates of abdominal symptoms consisting of abdominal pain and dyspepsia, which may persist or recur, collectively known as post-cholecystectomy syndrome. This article aims to (1) provide an overview of post-cholecystectomy syndrome with an emphasis on biliary complications and emergent imaging findings, (2) illustrate the spectrum of imaging findings of early and late post-cholecystectomy complications, (3) enumerate the role of various imaging modalities in evaluating post-cholecystectomy complications and address the role of selective trans-catheter coil embolization in managing bile leaks, and (4) discuss pearls and pitfalls in imaging following cholecystectomy. While common first-line imaging modalities for post-cholecystectomy complications include CT and sonography, ERCP and MRCP can delineate the biliary tree with greater detail. Scintigraphy has a higher sensitivity and specificity than CT or sonography for diagnosing bile leak and may preclude the need for ERCP. Post-operative complications include biliary duct injury or leak, biliary obstruction, remnant gallbladder/cystic duct stones and inflammation, biliary dyskinesia, papillary stenosis, and vascular injury. Subtle cases resulting in lethal outcomes, such as hemorrhage from the gallbladder bed without major vessel injury, have also been described. Cases presented will include biliary complications such as post-cholecystectomy stump cholecystitis, nonbiliary complications such as subcapsular hematoma, and normal post-surgical findings such as oxidized regenerated cellulose. Post-operative biliary complications can cause significant morbidity and mortality, and thus familiarity with the expected post-surgical appearance of the gallbladder fossa and biliary tract, as well as understanding the spectrum of complications and associated multimodality imaging findings, are essential for emergency radiologists and those practicing in the acute care setting to direct appropriate patient management. Furthermore, many of the postoperative complications can be managed by noninvasive percutaneous interventional procedures, from drain placement to cystic artery and cystic duct stump embolization.

[Complications of a lost gallstone]

ANAMNESIS

 An 88-year-old man presented with recurrent fever, weakness, and nausea without emesis for more than four months. Multiple hospital admissions followed, but the reason remained unclear. Eleven years previously, a laparoscopic cholecystectomy had been performed.

EXAMINATION

 Routine blood tests revealed leukocytosis and elevated C-reactive protein. A CT-scan of the abdomen revealed a big abscess extending from the intra-abdominal cavity to the subcutaneous tissue near the lumbovertebral column L2 to L5.

DIAGNOSIS

 We postulated an intra-abdominal abscess due to a lost gallstone after laparoscopic cholecystectomy 11 years ago.

TREATMENT AND FOLLOW UP

 The patient underwent surgery and was treated with antibiotics Postoperatively, he suffered from delirium. After prolonged secondary wound healing and antibiotic therapy, the patient was free of infection and could be discharged to his home after rehabilitation.

CONCLUSION

 Diagnosis was complicated by the clinical presentation, which is often atypical for geriatric patients. Diagnostic delays and recurrent hospitalizations increase the risk of morbidity and mortality. Although the gallstone was never retrieved, another cause of his symptoms was unlikely, as the patient has remained infection-free ever since.

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.

Dropped Gallstone Presenting as Recurrent Abdominal Wall Abscess

Dropped gallstones are a known complication of laparoscopic cholecystectomy. Rarely, dropped stones may be embedded within the potential intraperitoneal spaces or abdominal wall, mimicking metastatic implants, tuberculosis, peritoneal loose body, actinomyces, and primary tumors, which when coupled with the fact that most bile stones are radiolucent, leads to diagnostic challenges. Here, we report a case of abdominal wall abscess due to a dropped stone that presented over 15 years after laparoscopic cholecystectomy. An 86-year-old male with laparoscopic cholecystectomy for management of acute cholecystitis complicated by post-cholecystectomy choledocholithiasis over 15 years back presented to the emergency department with intermittent, asymmetric abdominal “bulging” and a reported 16-pound weight loss of 3 months duration. He remained hemodynamically stable and physical examination demonstrated approximately 9 cm × 7 cm, nontender and slightly fluctuant mass appreciable on the right lateral abdominal wall extending to the right flank. Laboratory revealed leukocytosis and elevated lactic acid. Abdominal ultrasound and abdominal computed tomography demonstrated a 10.6 × 7 × 16 cm cystic mass with echogenic debris adjacent to the anterior segment of the right hepatic lobe. The patient presented multiple times with re-accumulation. A drain was subsequently placed and antibiotic therapy initiated with subsequent resolution. Follow-up magnetic resonance imaging revealed a punctate calcification within the abscess pocket. Retained stones should be considered in the differentials of patients presenting with abdominal discomfort and abdominal “masses.” The clinical suspicion must remain high secondary to the potential temporally prolonged presentation, indolent nature of inflammation, and unusual sites of physical manifestations.

Achromobacter xylosoxidans Subdiaphragmatic Collection as a Result of a Dropped Stone During Laparoscopic Cholecystectomy

After a cholecystectomy, dropped stones can serve as a nidus for abscess formation. Intrabdominal abscesses tend to cause irritation and inflammation of the peritoneum and are thus rarely asymptomatic. This report discusses a 38-year-old female complaining of a recurrent right upper quadrant pain that led to multiple hospital admissions. Her surgical history was significant for cholecystectomy six years back complicated by a retroperitoneal abscess which was drained twice. A computed tomography (CT) scan was done, and she was diagnosed with a subdiaphragmatic collection as a result of a dropped stone.

A Case of Gallstones Causing Pelvic Pain

Introduction

Assessing abdominal pain, particularly in women of reproductive age, requires thorough history taking, clinical examination, and investigations to obtain an accurate diagnosis. Both surgical and gynecological causes need to be considered, particularly previous relevant surgical history. Presentation of case. We report a case of pelvic pain secondary to multiple gallstones found within the pelvic cavity postlaparoscopic cholecystectomy. Thorough investigations have been conducted without any obvious cause found. The pain was debilitating and largely affecting the patient's quality of life. Therefore, decision to perform diagnostic laparoscopy and gallstones was found all over pelvic cavity and retrieved. Her pain resolved post operatively.

Conclusions

Gallbladder perforation and stone spillage are the most common complications of laparoscopic cholecystectomy that arise during the removal and dissection of gallbladder and can cause significant morbidity if not managed early, especially retrieval of the stones intraoperatively. Therefore, patient with history of previous cholecystectomy with stone spillage presenting with undifferentiated abdominal pain and early diagnostic laparoscopy should be considered.

Dry Mopping vs. Saline Irrigation of Gallbladder Fossa After Bile Spillage During Laparoscopic Cholecystectomy: Randomized Control Trial

Introduction The laparoscopic approach, as compared to open cholecystectomy, is still considered the gold standard, despite a higher incidence of micro insults. The most common approach to treat spilled biliary contents and lost stones in laparoscopic cholecystectomy is the retrieval of the stone through an open approach, or laparoscopically, ending with a peritoneal wash and aspiration. Material and methods We conducted a double-blinded randomized controlled trial. In the study group, patients with bile spillage during cholecystectomy underwent suction of all spilled bile and evacuation of all visible stones followed by dry mopping of the gallbladder fossa with gauze swab through an epigastric port. In the control group, after suction of all bile and visible stones, the gallbladder fossa was washed with 250 ml of saline, and fluid was aspirated through the epigastric port. Results Sixty patients were included (30 patients in each group), 71.6% were female and the rest were male. There was a statistically significant difference in pain scores between the two groups (p=0.001). The dry mopping group had lower pain scores as compared to the other group postoperatively. The incidence of the intraabdominal collection in both groups are statistically insignificant, however, port site infection and intraabdominal collection are higher in the control group (irrigation group). Conclusion Although there is not much literature on the best approach to biliary spillage in laparoscopic cholecystectomy. We believe that dry mopping had better postoperative patient outcome as compared to the saline wash.

Post-cholecystectomy Gallstone Ileus

Gallstone ileus is an unusual complication of cholelithiasis. Classically, a stone is impacted at the terminal ileum originating from a cholecystoduodenal fistula. Exceptions to this pathophysiology have been noted at each step. In this systematic review, we document a comprehensive review of postcholecystectomy gallstone ileus inclusive of 49 separate cases and report 8 different mechanisms leading to this unusual complication. The most common mechanism is a lost stone during cholecystectomy that then erodes through the intestinal wall leading to bowel obstruction. Our review showed an older, female predominance (64.0%) at an average age of 68.0 years, patients typically had a burden of comorbidities. Delay in diagnosis was common (64% of cases) with the correct diagnosis made in 37.5% of patients during admission. Pneumobilia was commonly reported (29.0%). There was a wide range in the amount of time between cholecystectomy and gallstone ileus, from 10 days to 50 years (mean 12.4 years). Postcholecystectomy gallstone ileus is an unusual complication of cholelithiasis, which mandates surgery. Retrieval of stones should be undertaken if they are spilled during cholecystectomy. Owing to the increasing age of the American patient population, it is likely that a higher number of patients with this condition will be encountered.

Total Hip Lithiasis: A Rare Sequelae of Spilled Gallstones

Laparoscopic cholecystectomy is a surgical treatment for acute cholecystitis or symptomatic cholelithiasis. One potential complication, the spillage of gallstones into the peritoneal cavity, can form a nidus for infection and may be associated with hepatic, retroperitoneal, thoracic, and abdominal wall abscesses. We report a case of a patient presenting with a right iliopsoas abscess and an infected right hip prosthesis status postlaparoscopic cholecystectomy. A CT demonstrated that the acetabular shell was overmedialized and perforated through the medial wall. The patient was taken to the operating room for explantation of components. A collection of gallstones was identified deep to the acetabulum during the explantation. The case highlights the importance of avoiding overmedialization of the acetabular component, which can provide a direct route for infection into the hip joint.

Ultrasound-guided percutaneous retrieval of a dropped gallstone following laparoscopic cholecystectomy

Removal of intraabdominal dropped gallstones remains a challenging problem for both surgeon and radiologist. We describe in this report a novel, minimally invasive technique to successfully remove a dropped gallstone, causing recurrent intra-abdominal infection, from a patient who had undergone laparoscopic cholecystectomy.

Free Intraperitoneal Gallstone: An Unusual Case of Small Bowel Obstruction from Extrinsic Compression

Laparoscopic cholecystectomy (LC) is preferred in the treatment of symptomatic cholecystolithiasis. Gallstone spillage is not uncommon, and there have been reports of associated complications. We report a case of a free intraperitoneal gallstone, left inadvertently during LC, which developed an inflammatory phlegmon with abscess containing gallstone, causing extraluminal compression on the distal ileum, resulting in small bowel obstruction. This complication in particular is almost unheard of. The patient underwent laparoscopic drainage of abscess and retrieval of gallstone, which relieved the obstruction. Clinicians, therefore, need to keep an open mind in the workup for bowel obstruction. During LC, gallstone spillage should be prevented and retrieved whenever possible to minimize early and late complications associated with it.

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.

Perihepatic, Pulmonary, and Renal Abscesses Due to Spilled Gallstones

BACKGROUND

Spilled gallstones are common during laparoscopic cholecystectomy; however, they rarely lead to postoperative complications. Perihepatic abscesses develop in < 0.1% of patients with spilled gallstones and are typically contained within the peritoneal cavity.

CASE REPORT

We present a 57-year-old man with history of cholecystectomy 2 years prior who presented with cough and flank pain and was discovered to have a perihepatic abscess invading his lung and kidney secondary to a spilled gallstone. WHY SHOULD EMERGENCY PHYSICIANS BE AWARE OF THIS?: Although most perihepatic abscesses can be treated with percutaneous drainage and antibiotics, abscesses secondary to spilled gallstones usually require open or laparoscopic surgery to drain the abscess and retrieve the gallstone. Prompt identification of spilled gallstones in patients with intra-abdominal and intrathoracic abscesses can thereby guide disposition and decrease morbidity and mortality.

Dropped Gallstones Causing a Perihepatic Abscess and Empyema

Iatrogenic perforation of the gallbladder during laparoscopic cholecystectomy is a well-known occurrence; however, the consequences of spillage of gallstones in the peritoneum and particularly intrathoracic complications are less defined. We describe the delayed development of a perihepatic abscess and empyema in a patient five years following laparoscopic cholecystectomy secondary to dropped gallstones. A 53-year-old man with medical history significant for a laparoscopic cholecystectomy five years prior to acute cholecystitis presented with purulent cough, hemoptysis, night sweats, and right-upper quadrant (RUQ) pain. Computed tomography (CT) scan revealed 5.4 cm right-sided subpulmonic and 5.9 cm perihepatic fluid collections with an 8 mm focal radiopaque density within the perihepatic fluid collection. Open intra-abdominal exploration resulted in retrieval of a 1 cm intraperitoneal gallstone. Laparoscopic cholecystectomy is a common surgical operation during which gallstone spillage can occur, causing both intra-abdominal and intrathoracic complications, presenting even years after surgery. This necessitates an attempt to retrieve all free intra-abdominal gallstones during the initial operation.

Immediate postoperative pain: an atypical presentation of dropped gallstones after laparoscopic cholecystectomy

Cholecystectomy is one of the most commonly performed surgical procedures in the United States. A common complication is dropped gallstones, and the diversity of their presentation poses a substantial diagnostic challenge. We report the case of a 58-year-old man presenting with chronic right upper quadrant hours status post cholecystectomy. Imaging demonstrated retained gallstones in the perihepatic space and symptoms remitted following their removal via laparoscopic operation. Gallstones are lost in roughly 1 in 40 cholecystectomies and are usually asymptomatic. The most common presentations are months or years status post cholecystectomy due to fistula, abscess, or sinus tract formation. We report this case hoping to bring light to a rare presentation for dropped gallstones and provide advice on the management of this common complication of cholecystectomy.

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.

Laparoscopic management of chronic abscess due to spilled gallstones

INTRODUCTION

Bile and gallstones are spilled during 13% to 40% of all laparoscopic cholecystectomies. They can act as a septic focus and cause complications. We present 2 cases of perihepatic abscess formation due to dropped gallstones presenting some years later. Delayed diagnosis resulted in unnecessary investigations and had negative economic consequences.

CASE DESCRIPTION

In 1 patient a posterolateral cutaneous fistula had developed that was initially biopsied by cardiothoracic surgeons before computed tomography showed the cause. The other patient presented with recurrent Pyrexia of unknown origin (PUO) causing repeated absence from work and was diagnosed only after 18 months of medical investigation. Both patients were treated with laparoscopic drainage of the abscess and successful retrieval of all stones.

DISCUSSION

Radiologic and open drainage and retrieval of stones have been well described in these cases. We suggest that a laparoscopic approach is superior because the cavity can be clearly identified and stones visualized and removed under direct vision. The need for a formal laparotomy is avoided. We also highlight the economic burden to both patient and health care professional of delayed diagnosis, as shown in these 2 cases. Spilled gallstones are a recognized complication of laparoscopic cholecystectomy. All stones should be actively sought and removed to avoid complications. Laparoscopic drainage is preferable to open or radiologic drainage. Dropped gallstones should be considered a possible diagnosis in patients who have had a previous cholecystectomy and present with unusual symptoms.

Knowledge and practices of general surgeons and residents regarding spilled gallstones lost during laparoscopic cholecystectomy: a cross sectional survey

BACKGROUND

Gall bladder perforation, gallstone spillage and loss are commonly reported from Laparoscopic Cholecystectomy (LC). Though rare, lost gallstones can cause a variety of complications presenting variably from within 1 month to 20 years postoperatively. Our objective was to investigate knowledge and practices of surgeons and surgical residents regarding spilled gallstones lost during laparoscopic cholecystectomy.

METHODS

An observational, cross-sectional survey, using a questionnaire based on 13 self-answered close-ended questions, was conducted at 6 different post-graduate centers in Karachi, Pakistan.

RESULTS

Of the 82 participants, 23 (28%) were consultant surgeons while 59 (72%) were general surgery residents. 86% of participants were aware that stones lost during LC can cause complications. Out of the 18 reported complications presented, only 20% participants identified more than 8 complications for which they can consider lost gallstones causal. 28% of participants weren't aware about the expected postoperative duration for presentation of complications. Only 15% of our participants expected complications beyond 5 years of the procedure. 72% of participants will not convert to open cholecystectomy to retrieve lost gallstones. While 88% of participants agreed that lost gallstones should be documented in operative notes, only 70% reported that it's actually done in practice. 55% of participants agreed to have possibility of lost gallstones as part of the informed consent but in practice it's included according to only 31% of participants. 68% of participants believe that patients should be informed if gallstones are lost but in actual practice only 41% participants inform patients when gallstones are lost during procedure.

CONCLUSIONS

We conclude that there is a dearth of awareness regarding diversity of complications from lost gallstones and about their variable postoperative duration of presentation. The practices involving lost gallstones management, documentation and patient information were found to vary widely. Proper awareness is imperative as it may compel surgeons to undertake all possible measures to retrieve spilled gallstones and progress towards better and standardized practices in managing lost gallstones.

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.

Gallstone-related abdominal abscess 8 years after laparoscopic cholecystectomy

An unusual collection of fluid in the perihepatic space needs to be investigated for abscess in patients with a remote history of cholecystectomy.

Background:

A common intraoperative complication during laparoscopic cholecystectomy is gallbladder perforation with spillage of gallstones. The undesirable consequence of spilled gallstones is the formation of abscesses months or years after an operation.

Case Description:

Our clinical report describes an intraabdominal abscess formation in an 82-year-old man that developed 8 years after a laparoscopic cholecystectomy. A computed tomography scan of the abdomen showed an elongated fluid collection in the right abdominal compartment musculature at the level of the internal oblique muscle. Abdominal ultrasonography confirmed a large fluid collection, with 2 echogenic masses in the dependent portion. Incision and drainage of the abscess were performed, and 2 gallstones were found.

Conclusion:

Any unusual collection of fluid in the perihepatic space and abdominal wall in the area of the surgical incision in a patient with a remote history of cholecystectomy should be evaluated for abscess related to retained gallstone. Early abscess formation is usually diagnosed and treated by the surgeon. However, the late manifestation might be a clinical problem seen in the primary care physician's office. Therefore, the primary care physician should incorporate diagnosis of gallstone-related abscess in patients with abdominal abscess formation of unknown etiology.

Fate of lost gallstones during laparoscopic cholecystectomy

Backgrounds/Aims

The fate of gallstones that remain in the peritoneal cavity due to perforation of the gallbladder during laparoscopic cholecystectomy (LC) has been studied vigilantly since the early 1990s when this surgical procedure started to be used. But the complication statistics vary with each report. So we reviewed our 47 cases of lost stones that were traceable from 1998 to 2007.

Methods

Stones entered the peritoneal cavity through the perforation site during dissection of the body or Hartmann's pouch of gallbladder from the liver bed, despite trials of stone removal like irrigation and using a glove finger pouch especially in the case of numerous small stones. There were nine cases of lost stones that were caused by fragments of stone breaking from a large stone during its retrieval.

Results

No patient was forced into revision surgery or intervention for the missing stones but only negative suction drains were inserted, and information to the patients was given. Most of the stones (N=42, 89.4%) remained silent during the follow-up period of 10.4±3.6 years, and 5 patients (10.6%) developed inflammatory complications in the peritoneal cavity and abdominal wall. Two intraperitoneal abscesses were found in the right subhepatic area and a cul-de-sac and these were managed by laparotomy. Subhepatic abscess was later associated with intestinal obstruction. Two patients suffered an umbilical portal site fistula and a right flank portal fistula respectively, requiring prolonged wound care. One patient suffered immediate postoperative peritonitis that was cured by antibiotics.

Conclusions

Lost stones should be retrieved or fragmented as much as possible for removal through a drain, and caution should be exercised during dissection of the gallbladder to avoid perforating the gallbladder. Considering the approximately 10% incidence of serious inflammatory complications of lost stones, the complications should be explained to patients to allow for earlier diagnosis of complications later.

Monopolar electrocautery versus ultrasonic dissection of the gallbladder from the gallbladder bed in laparoscopic cholecystectomy: a randomized controlled trial

BACKGROUND

Ultrasonic dissection has been suggested as an alternative to monopolar electrocautery in laparoscopic cholecystectomy because it generates less tissue damage and may have a lower incidence of gallbladder perforation. We compared the 2 methods to determine the incidence of gallbladder perforation and its intraoperative consequences.

METHODS

We conducted a prospective randomized controlled trial between July 2008 and December 2009 involving adult patients with symptomatic gall stone disease who were eligible for laparoscopic cholecystectomy. Patients were randomly assigned before administration of anesthesia to electrocautery or ultrasonic dissection. Both groups were compared for incidence of gallbladder perforation during dissection, bile leak, stones spillage, lens cleaning, duration of surgery and estimation of risk of gallbladder in the presence of complicating factors.

RESULTS

We included 60 adult patients in our study. The groups were comparable with respect to demographic characteristics, symptomatology, comorbidities, previous abdominal surgeries, preoperative ultrasonography findings and intraoperative complications. The overall incidence of gallbladder perforation was 28.3% (40.0% in the electrocautery v. 16.7% in the ultrasonic dissection group, p = 0.045). Bile leak occurred in 40.0% of patients in the electrocautery group and 16.7% of patients in ultrasonic group (p = 0.045). Lens cleaning time (p = 0.015) and duration of surgery (p = 0.001) were longer in the electrocautery than the ultrasonic dissection group. There was no statistical difference in stone spillage between the groups (p = 0.62).

CONCLUSION

Ultrasonic dissection is safe and effective, and it improves the operative course of laparoscopic cholecystectomy by reducing the incidence of gallbladder perforation.

Consequences of spilt gallstones during laparoscopic cholecystectomy

To document the incidence of spilt gallstones during laparoscopic cholecystectomy, the cause and consequences of such spillage. The study included 150 consecutive laparoscopic cholecystectomies performed between October 2007 and November 2008. Data was collected in a prospective manner in accordance to proforma. Follow up were performed at the end of 1 week, 1 month, 6 months and 1 year. The spillage of gall stones during surgery occurred in 19.04 % of the cases. Majority of the spillage occurred due to perforation of the gall bladder during dissection, followed by application of toothed grasper. Although all visible spilt stones were retrieved during surgery, complication rate of 0.66 % was observed. The incidence and complications secondary to the spillage of gall stones during standard laparoscopic cholecystectomy is low but avoidable. Various complications can occur, over a large period of time. Thus it is advisable to retrieve as many gallstones as possible short of converting to a laparotomy Dasari and Loan (JSLS 13(1):73-76, 2009), Daradkeh and Suwan (World J Surg 22:75-77, 1998).

Spilled gallstones mimicking peritoneal metastases

BACKGROUND

Spillage of bile and gallstones due to accidental perforation of the gallbladder wall is often encountered during laparoscopic cholecystectomy. Although spilled stones were once considered harmless, there is increasing evidence that they can result in septic or other potential complications.

CASE REPORT

We report a case of spilled gallstones mimicking peritoneal metastases on radiological investigations; diagnosis was confirmed by diagnostic laparoscopy.

CONCLUSION

Every effort should be made to retrieve spilled gallstones during laparoscopic cholecystectomy. When all the stones cannot be retrieved, it should be documented in the patient's medical records to avoid delay in the diagnosis of late complications. Diagnostic laparoscopy is useful when the radiological investigations are inconclusive.

The case for standardisation of the management of gallstones spilled and not retrieved at laparoscopic cholecystectomy

INTRODUCTION

This observational study was carried out to establish how surgeons performing laparoscopic cholecystectomy currently deal with the issue of spilled gallstones.

MATERIALS AND METHODS

A questionnaire was circulated amongst laparoscopic surgeons attending the annual conference of the Association of Laparoscopic Surgery of Great Britain and Ireland in November 2006.

RESULTS

Eighty-two surgeons completed the questionnaire. Only half of surgeons inform patients when gallstones are spilled. Less than 30% of surgeons inform general practitioners (GPs) of this complication, when it occurs. Less than a quarter of surgeons include this information in the consent literature provided to patients.

CONCLUSIONS

We recommend that trusts review their policy towards spilled stones either by local audit or adopt the guidance given by the UK Healthcare Commission. While some surgeons feel informing patients and GPs may unnecessarily heighten anxiety from an uncommon complication, our review of the literature suggests this position is not tenable in the current medicolegal climate.

Spilled gallstones: the source of an enigma

Spillage of gallstones may occur in the course of laparoscopic cholecystectomy. The incidence of this mishap and its consequences are variable. Ignored by many surgeons, stone spillage may be the source of significant morbidity many years after surgery. In this report, we describe the clinical course of a patient who presented with upper abdominal pain and swelling. The past history was positive for laparoscopic cholecystectomy 15 years earlier. After excision, the swelling was found to be a pseudocyst formed around spilled gallstones during a previous cholecystectomy. Apart from postoperative wound infection, the patient recovered well and remains so. Here, we discuss the problem and provide suggestions for spillage prevention and stone retrieval once spillage occurs.

Gallstone spillage caused by spontaneously perforated hemorrhagic cholecystitis

There are occasional incidences of gallstone spillage during laparoscopic cholecystectomy, and there have been frequent reports on such a topic in the literature. To the best of our knowledge, however, there have been no reports about spilled stones caused by spontaneously perforated hemorrhagic cholecystitis. Here, we report the radiologic findings of spilled stones caused by spontaneously perforated hemorrhagic cholecystitis in a 55-year-old man.

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.

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.

Errors in laparoscopic surgery

Laparoscopic surgery is the most significant advancement in the field of surgery over the past 15 years. This minimal access approach has been widely embraced and adopted to many common operations. Demonstrated benefits include decreased post-operative pain, shorter lengths of in-patient hospitalization, increased patient acceptance, and a more rapid return to gainful employment. With its ever-growing popularity, it has become fertile ground for civil litigation, ranking along with birth injuries and failure to diagnose cancer. A brief synopsis of the history of its evolution is presented along with general and specific comments concerning potential errors as they relate to specific common operations which are commonly done utilizing this technique.

Current status of laparoscopic therapy of cholecystolithiasis and common bile duct stones

BACKGROUND

Laparoscopic cholecystectomy (LC) is the standard operation for gallstone disease. The aim of this review was to scrutinize the advantages and benefits of this minimal invasive technique compared to the conventional operation according to the available literature. Regarding the evidence-based medicine criteria, the current status of laparoscopy in the treatment of cholecystolithiasis, cholecystitis and common bile duct stones has been worked out.

METHODS

A Medline, PubMed, Cochrane search.

RESULTS

Ten randomized controlled trials (RCTs) are available comparing laparoscopic versus open cholecystectomy. The superiority of LC in less postoperative pain, shorter recovery and hospital stay is stated. Operation time was longer in the first years of LC. 3 RCTs deal with acute cholecystitis: one paper could not find any significant advantage of LC over conventional cholecystectomy, the other two found benefits in recovery, hospital stay and postoperative pain. The range of conversion is between 5 and 7% in elective cases and increases up to 27% for acute cholecystitis. With a rate of more than 90% in Europe, the standard procedure for common bile duct stones is 'therapeutic splitting' with endoscopy and retrograde cholangiopancreatography preoperatively followed by LC. Laparoscopic bile duct clearance is effective and safe in experienced hands, however, the only proven benefit is a slightly shorter hospital stay.

CONCLUSION

The laparoscopic approach is preferred in elective cholecystectomy and acute cholecystitis. The minimal invasive technique has proven to be effective, gentle and safe. The main benefits are evident within the first postoperative days.

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.

Randomized clinical trial of ultrasonic versus electrocautery dissection of the gallbladder in laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is frequently complicated by gallbladder perforation and loss of bile or stones into the peritoneal cavity. The aim of this study was to compare the use of ultrasonic dissection and electrocautery with respect to the incidence of gallbladder perforation and intraoperative consequences.

METHODS

Between January 1998 and January 2000, 200 patients undergoing elective laparoscopic cholecystectomy were randomized to electrocautery or ultrasonic dissection of the gallbladder. The main outcome measures were gallbladder perforation, operating time and the number of times the lens was cleaned. Univariate and multivariate analyses were performed.

RESULTS

The perforation rate differed significantly: 16 per cent for ultrasonic dissection (n = 96) and 50 per cent for electrocautery (n = 103) (P < 0.001). The operating time of the least experienced surgeons, who had performed fewer than ten laparoscopic cholecystectomies, was significantly shorter when ultrasonic dissection was used, compared with electrocautery. The number of times the lens needed to be cleaned was significantly lower when ultrasonic dissection was used in complicated gallbladders (P < 0.035). At logistic regression analysis, the risk of perforation in the electrocautery group was about four times higher (odds ratio 0.26, P < 0.001) than that in the ultrasonic group. When the groups were matched for prognostic factors, including body mass index and surgical experience, the results were similar to those obtained with univariate and multivariate analysis.

CONCLUSION

The use of ultrasonic dissection in laparoscopic cholecystectomy reduces the incidence of gallbladder perforation and helps the operation to progress. Less experienced surgeons benefit most from ultrasonic dissection, particularly in complicated intraoperative circumstances.

Digestive complications of gallstones lost during laparoscopic cholecystectomy

INTRODUCTION

Serious complications can ensue if a gallstone is dropped into the peritoneal cavity during laparoscopic cholecystectomy and not retrieved.

CASE OUTLINE

A 75-year-old-man was admitted with intestinal obstruction 8 years after laparoscopic cholecystectomy. Ultrasound scan and a contrast x-ray of the small bowel showed a gallstone within the small bowel lumen that CT scan had failed to identify. Laparotomy showed a Meckel's diverticulum plus a 4 x 6-cm gallstone in the terminal ileum. The gallstone had penetrated into the Meckel's diverticulum before migrating into the ileum and obstructing it.

DISCUSSION

Gallstones lost during laparoscopic cholecystectomy can cause an intraperitoneal abscess. In addition, they can migrate through the anterior or posterior abdominal wall or the diaphragm and into the urinary tract or bronchus. The resulting abscess can obstruct the digestive tract or drain into the digestive tract to cause a communicating abscess. It can also drain through the abdominal wall and the digestive tract to cause an enterocutaneous fistula. Lastly, the stone can migrate into the intestine and cause gallstone ileus. Following laparoscopic cholecystectomy, patients with a lost gallstone may suffer from abdominal pain and fever within days or months. Thus, all dropped gallstones should be removed during laparoscopy.

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%.

Spilled gallstones after laparoscopic cholecystectomy

Spilled gallstones have emerged as a new issue in the era of laparoscopic cholecystectomy. We treated a 77-year-old woman who underwent laparoscopic cholecystectomy. Subsequently, a right flank abscess developed. During the cholecystectomy, the gallbladder was perforated and stones were spilled. After a failed attempt to drain the abscess percutaneously, the patient required open drainage, which revealed retained gallstones in the right flank. The abscess resolved, although the patient continued to have intermittent drainage without evidence of sepsis. Review of the literature revealed 127 cases of spilled gallstones, of which 44.1% presented with intraperitoneal abscess, 18.1% with abdominal wall abscess, 11.8% with thoracic abscess, 10.2% with retroperitoneal abscess, and the rest with various clinical pictures. In case of gallstone spillage during laparoscopic cholecystectomy, every effort should be made to locate and retrieve the stones.

Remote complications of spilled gallstones during laparoscopic cholecystectomy: causes, prevention, and management

In the last 11 years (November 1989-December 2000), 5526 laparoscopic cholecystectomies were performed in a community residency training program. Two cases (0.04%) of remote complications secondary to spilled gallstones were identified. A 75-year-old woman presented with a sterile abscess in the abdominal wall containing gallstones 4 years and 4 months after an elective laparoscopic cholecystectomy. The second patient, a 43-year-old woman, presented with a subdiaphragmatic/subhepatic abscess containing gallstones. The abscess grew the same bacteria that were present 2 years and 3 months previously during a laparoscopic cholecystectomy for acute gangrenous cholecystitis. In both cases, pigmented gallstones were identified. Causes of gallstone spillage, means of prevention, and ways of managing this complication are discussed.

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.