Complications of spilled gallstones following laparoscopic cholecystectomy: a case report and literature overview

Certain situations lead to higher risk of gallbladder perforation during laparoscopic cholecystectomy. Patients with acutely inflamed gallbladders have friable tissue which is susceptible to tear. Dense adhesions around the gallbladder make dissection potentially more difficult, and a tense, distended gallbladder that has not been decompressed is at risk of perforation [1, 3]. This usually occurs when the gallbladder is manipulated by laparoscopic instruments or when it is dissected from the liver bed. Spilled stones are also caused by the slipping of the cystic duct clip or the tearing of the gallbladder while it is retrieved from the port site [4]. There is also a well recognised learning curve for performing laparoscopic cholecystectomies, and the risk of perforation is high early in a surgeon's laparoscopic career [1].

Although lost gallstones were initially considered innocuous, it is now recognised that they can be a small but significant source of postoperative morbidity (0.1 to 6%) [4]. The presentation of complications will vary from patient to patient, and depend largely on the site and type of complication suffered. Recognised symptoms include abdominal pain, fever, abdominal masses, bowel obstruction and the presence of a sinus infection or fistula [2, 5]. In some cases, the presenting mass has been diagnosed as malignancy until further investigations have disproved this. In most instances, the diagnosis is made retrospectively, or after visualisation of the stones on imaging and revisiting the patient's surgical history.

Most complications occur within the first few months, but presentations up to ten years after the procedure have also been documented [6]. Zehetner et al. looked into all documented complications from lost gallstones and these ranged from the most common like intra-abdominal and subcutaneous abscesses and fistulas, to the less common, such as liver abscess, staphylococcus bacteraemia, broncholithiasis and expectoration, empyema, granulomas, bowel obstruction and incarceration within a hernial sac [5].

Studies also show risk factors for complications after spilled stones, such as the presence of infected bile, spillage of pigmented gallstones, multiple stones (>15), stone size (>1.5 cm) and old age [5].

The best way to avoid complications from lost gallstones is to have awareness of the situations where perforation is likely, perform precise dissection, meticulously handle tissue and use devices such as endobags to retrieve dissected gallbladders through the port sites. Perforation usually occurs when dissecting the gallbladder from the hepatic fossa, and care taken at this stage of the operation can save many minutes attempting to retrieve stones from within the peritoneum [7].

Despite all precautionary measures, it is unavoidable that gallbladder perforation and stone spillage still occur in some patients. In these cases, it is crucial to minimise the number of stones spilled, attempt to retrieve all stray stones and to copiously irrigate the peritoneal cavity [4]. This serves the purpose of diluting any infected bile and may allow the stones to be washed up into the suction system. Some surgeons advocate the use of clips or an endoloop to close the hole in the gallbladder, while others will introduce a retrieval bag and 'park' it on the liver to receive all spilled stones [7]. In some situations it may be necessary to use an extra port adjusted to a 30- or 45-degree scope or use a fan liver retractor to improve visualisation [4].

Antibiotic prophylaxis is not routinely used by everyone, but its therapeutic use has been suggested for patients who undergo laparoscopic cholecystectomy to treat acute cholecystitis, have visibly infected bile, or have a high probability for lost stones. However, antibiotics should not be administered until the bile and stones have been collected for examination and culture, which would allow for the antibiotic selection to be tailored to the patient's condition [5].

Possibly the most important aspect in the management of perforated gallbladders and potential stone spillage is documentation. As already mentioned, diagnosis of complications related to lost stones is often done only after the identification of gallstones on radiological imaging. If the documentation is clear and the patient is aware of the perforation, then clinicians may be alerted early to the possibility of a stone complication in order to expedite treatment.

The imaging method of choice is usually ultrasound, as stones are usually visualised well using this method. Visualisation, however, depends on the location of the lost stones. CT and magnetic resonance imaging (MRI) can also be used to obtain adjunct images depending on the biochemical composition of the stone. Radio-opaque calcified stones, such as pigmented stones, can be seen clearly on CT with unenhanced pictures. On MRI most stones are hypo-intense on T2-weighted images and iso-intense to hyperintense on T1-weighted images. These are best seen without fat suppression as this allows for the contrasting features of the stone to be seen against the fat [8]. Sometimes the radiological findings mimic unusual diagnoses such as actinomycosis, hydatid disease or even malignancy, so diagnosis can be difficult [1]. Ultimately, abscesses should be drained, whether percutaneously or surgically, and the stones should eventually be removed. Ideally this is done via minimally invasive techniques, but open surgery is often required. However, in our case, the patient was not keen on further invasive procedures and so for her the sequelae of lost stones may continue for years.