Authored by May Thu Kyaw and Tai-Ping Lee
Abstract
Gallstones can spill into the peritoneal cavity during laparoscopic
cholecystectomy. It can cause a silent peritoneal stone and escalate to
intraperitoneal complications such as abscess, peritonitis and
perforation of intestine from two months up to twenty years. Spilled
stone can lead
to chronic perihepatic fluid collection, subphrenic abscess and severe
life-threatening complications such as sepsis. Every action should be
taken to
avoid spilling gallstones during the surgery. It warrants high clinical
suspicion and requires appropriate interventions. We reviewed
complications
and management of spilled gallstones after laparoscopic cholecystectomy
[1].
Case Report
Case 1
Patient is a 76-year-old man with past medical history
of hypertension, type 2 diabetes mellitus, hyperlipidemia,
coronary artery disease, chronic renal insufficiency, alcoholic
cirrhosis who was diagnosed with cholelithiasis in 2015. He
subsequently developed cholecystitis, which was complicated by
choledocholithiasis with cholangitis, requiring ERCP with biliary
stent, followed by laparoscopic cholecystectomy. There was no
documentation of spilled stones or any other complication during the
surgery. Two years after laparoscopic cholecystectomy [2], patient
presented with abdominal distention and pain predominantly in
the epigastric region, not related to food. Abdomen CT scan showed
subphrenic fluid collection extending along right abdominal wall
with two to three calcified spilled gallstones. During the hospital
course, patient developed fever, leukocytosis and tachycardia. He
was diagnosed with sepsis and treated for suspected pneumonia.
Patient underwent interventional radiology (IR) guided drainage
for multiloculated complex hepatic fluid. Eight hundred milliliters
of greenish viscous fluid were aspirated [3]. Culture from
intraperitoneal aspiration is negative. IR failed to remove gallstone
after dilating the access. Patient underwent an extensive peritoneal
washout and perihepatic fluid collection resolved Figure 1.
Case 2
A 72-year-old woman with history of laparoscopic
cholecystectomy 2 years ago presented with right sided abdominal
pain, vomiting and fever. Patient was known to have spilled gallstone
in peritoneum post cholecystectomy, require intraperitoneal drain [4].
Abdominal CT scan showed three collections; a 3.2x8.3x8.9 cm
multiloculated collection tracking around the right posterolateral
aspect of the chest and abdominal wall posterior to the area of liver,
at the level of the 10th rib with a small calcified focus suspicious
for gallstone, an additional area of soft tissue attenuation adjacent
to the collection, lateral to the ascending colon representing
phlegmonous change, and a 2x3x5.9 cm multiloculated collection
within the anterolateral right abdominal wall near the location of
the previous surgical drain. At the same time, patient developed a
strangulated ventral hernia requiring emergency open reduction
surgery. She was started on antibiotics for abdominal abscess and
abdominal drainage. Subsequently, a small gallstone appearing as
clip in the center of the abscess cavity was removed. Follow up CT
abdomen showed decrease in the size of the abscess cavity. Patient
clinically improved and abscess eventually resolved Figure 2.
Case 3
54 year-old-woman with history of gastric bypass surgery
and laparoscopic cholecystectomy about 6 years ago, presented
with perihepatic fluid collection from spilled gallstone [5,6].
Patient developed chronic supraumbilical fullness and abdominal
distention and found to have increased right subcapsular
perihepatic fluid collection on serial abdominal CT scan. Patient
underwent IR guided drainage for perihepatic fluid collection, but
the fluid collection recurred to 6.1 x 3.4 x 6.6 cm after drainage was
removed. She was treated with broad spectrum antibiotics. Patient
underwent repeat laparoscopic hepatic infected fluid drainage
[7]. Patient was treated with Ciprofloxacin and Metronidazole for
Penicillin sensitive E. coli in infected fluid. Follow up abdominal
CT abdomen three months later showed decrease in size of the
cavity to 4.3 x 1.6 x 5.0 cm after percutaneous drainage removal.
Patient is under surveillance for recurrence of perihepatic fluid and
peritoneal wash out is planned Figure 3.
Discussion
Traditional open cholecystectomy was replaced by laparoscopic
cholecystectomy for symptomatic gall stones due to shorter
dursation of hospital stay, fewer complications, faster recovery
time, and less pain [8]. 1,2 Bile duct injury, gall bladder perforation,
spillage of gallstone are more common with laparoscopic procedure.
Spillage of gallstones occur in 25-30% cases after laparoscopic
cholecystectomy.3 Twenty percentage of gallstone spillage was
unnoticed by the surgeon although long term consequences from
spilled gallstone are extremely rare.2 The composition of the stones
and the component of the bile are the main indicators for future
complications of symptomatic spilled gallstones.4 As per Aytekin
et al experimental studies with a rat model shows spilled gallstones
increase the risk for postoperative adhesion.5 Patients with acute
cholecystitis have increased incidence of spillage of infected
gallstones and also have higher rate of complications.6 The onset
of the complication varies from a few months to 20 years.7 Intraabdominal
fluid collection or abscess, abdominal wall abscess and
fistula formation are seen in descending order. The most common
intra-abdominal fluid or abscess is perihepatic in subphrenic area
as in our patient. 8 Every attempt should be made to retrieve stone
lost during laparoscopic cholecystectomy due to increased risk of
complications in the future.9 However, not enough data has been
reported whether dropped gallstones should be chased during
procedure by transforming into open laparotomy. The best option
is the primary prevention which include avoiding the gall bladder
perforation, using specimen bag to avoid gallstones leakage, and
detail documentation of the spilled stones.10 Every attempt should
be made during the procedure to retrieve the stones dropped into
the abdominal cavity [9]. Conversion to open procedure to retrieve
the stones as secondary prevention is supported when there
is infected stones, multiple stones, or suspicion of bacterobilia.
Management of abscess from dropped stone depends on the
location and size of the abscess. Intravenous antibiotics, saline
irrigation and percutaneous IR guided drainage are the treatment
of choice for small subphrenic abscess. Calculi in deep seated
intraperitoneal pouch which are difficult to access may need open
procedure if patient has persistent symptoms [10]. Ultimately, all
the stones should be removed while draining the abscess to prevent
further irritation and recurrent abscess.
Conclusion
Complications arising from spilled gallstones are uncommon.
They could take months to years to occur and can sometimes lead
to severe comorbidities such as adhesion with small intestinal
obstruction, abscess formation and sepsis. Therefore, high
suspicion for diagnosis is necessary. Every possible effort should
be made to prevent and retrieve the infected or noninfected spilled
gallstones during the procedure due to potential complications.
However, it is controversial whether it should be converted to
open surgery to retrieve a spilled gallstone. Irrigation of abdominal
cavity after gall bladder perforation as primary prevention and
percutaneous drainage of intra-abdominal abscess are the main
stay of management.
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