Laparoscopic Management of Gallstone Ileus

Excerpt

A 93-year-old woman was admitted to our unit with a 3-week history of right hypochondrium pain that had evolved acutely in the last 2 days. Her medical history included major cardiovascular diseases and a hysterectomy performed 40 years earlier. Clinical examination revealed non-specific diffuse abdominal tenderness with abdominal distension, vomiting, and loss of flatus, suggesting an adhesive intestinal obstruction. Routine admission blood tests demonstrated moderate sepsis and acute functional kidney failure, without liver function test abnormalities. Non-injected abdominal computed tomography (CT) was performed, and signs of chronic cholecystitis, pneumobilia with cholecysto-enteric fistula, and small-bowel obstruction due to a 3-cm gallstone impacted in the last jejunal loop were found (Fig. 1). The diagnosis of gallstone ileus was made, and the patient was taken to the operating room to undergo an emergency coelioscopy. The exploration showed small-bowel dilation but failed to reveal the gallbladder because of tight omental adhesions. After distal bowel adhesiolysis, the last jejunal loop was found and the gallstone localized. A 4-cm longitudinal enterotomy at the anti-mesenteric border was carried out and the impacted stone was brought out. The enterotomy was then closed by a continuous suture of absorbable monofilament (Fig. 2). Because of predictable surgical difficulties in this high-risk patient, we chose not to remove the gallbladder to avoid dealing with the cholecysto-enteric fistula repair. The postoperative course was uneventful and the patient was discharged on day 8 post-surgery.

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