Complications of Gallstones Lost During Laparoscopic Cholecystectomy

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Health Care Article of the month

January 1999

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Complications of Gallstones Lost During Laparoscopic Cholecystectomy

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Abstract

Gallstone spillage at the time of laparoscopic cholecystectomy occurs in

approximately 5% of procedures. Stones left in the abdominal cavity were

initially considered harmless, but recent reports have implicated spilled

stones as a source of infrequent but serious complications of laparoscopic

cholecystectomy. In most cases the patient requires open operation for

management of these complications. Two such complications are reported: a

mechanical small bowel obstruction secondary to spilled stones that

required prompt laparotomy, and a lateral port site abscess that became a

draining sinus until complete evacuation of the stones was achieved.

Introduction

Laparoscopic cholecystectomy has become the preferred method of treatment

for symptomatic gallstones since its introduction in 1987. Initially,

stones left in the abdominal cavity after laparoscopic cholecystectomy were

considered harmless,[1] and early clinical and experimental studies

supported this opinion.[2-5] However, cumulative reports of cases suggest a

potential danger.[6-9]

This article describes 2 major complications arising from spilled stones

during laparoscopic cholecystectomy: a mechanical small bowel obstruction

and a lateral port site abscess. Both complications required open operation.

Case Reports

Patient 1.

A 67-year-old woman was diagnosed to have cholelithiasis. Ultrasonography

revealed a single gallstone larger than 30mm in diameter, for which she

underwent laparoscopic cholecystectomy. During the retrieval of the

gallbladder through the subumbilical incision, the gallbladder broke and

the fragments of the stone dropped over the omentum. An effort was made to

retrieve the fragments; however, some were lost between loops of bowel. The

patient had an uncomplicated recovery and was discharged the following day.

On postoperative day 7, the patient was readmitted to the hospital with

severe abdominal cramping, nausea, vomiting, and dehydration. Her abdomen

was tender and bowel sounds were increased. Abdominal films confirmed the

presence of a mechanical small bowel obstruction. She was treated with

nasogastric intubation and intravenous fluids. Twenty hours after

admission, the patient became febrile and her abdominal tenderness had

increased.

She underwent immediate exploratory laparotomy. At the time of exploration,

multiple kinks and adhesions between loops of terminal ileum were

identified and easily separated. Fragments of stone between adherent and

angulated loops were removed. Some fragments were covered by loops of

terminal ileum. There was no bowel perforation. The patient had an

uncomplicated recovery from the operation and was discharged on

postoperative day 6.

Patient 2.

A 47-year-old woman was referred to the surgical clinic at Mersin State

Hospital with a 3-day history of right upper quadrant pain associated with

nausea and vomiting. On physical examination, severe right upper abdominal

tenderness was noted, but no evidence of generalized peritonitis was found.

Ultrasonography revealed a gallbladder with a 4-mm wall and multiple stones.

Laparoscopic cholecystectomy was performed the same day. During dissection

from the liver bed, the gallbladder ruptured and several stones fell under

the liver. An effort was made to retrieve the spilled stones. The patient

was discharged on postoperative day 2.

Fourteen months after the operation, the patient returned to the hospital

with a complaint of swelling of her right upper quadrant near the lateral

trocar site. She also had fever and chills. Ultrasonography showed an

abdominal wall fluid collection and an image compatible with a stone. Under

local anesthesia, an incision was made and drainage was performed, which

yielded 50mL of pus and an 8-mm stone.

A culture from the abscess cavity grew Klebsiella pneumoniae, and the

pathology report confirmed the presence of a calcium bilirubinate

gallstone. After decompression of the cavity, a small sinus tract developed

with intermittent purulent drainage.

During the following 3 months she was asymptomatic, but intermittent

drainage from the sinus tract persisted. Ultrasonography and computerized

tomography of the abdomen were normal. A fistulogram showed a 30-mL cavity

to the right of the xiphoid and under the costal margin (Fig. 1). There was

no connection to the peritoneal cavity.

A subcostal incision was made and a well-formed cavity, located just under

the subxiphoid port site, was opened. The sinus tract was open to the

lateral port site. On further exploration, 2 gallstones, each approximately

7 to 8mm, were found in the cavity. The stones and debris were removed, and

the patient made an uneventful recovery.

Discussion

The incidence of gallbladder perforation during laparoscopic

cholecystectomy has been reported to range from 8%[10] to 32%.[1] It is

usually the result of rupture of a gangrenous gallbladder, tearing of the

gallbladder by the grasping forceps, or piercing of the back of the

gallbladder when dissecting it away from the liver.

The spillage of stones occurs less frequently than gallbladder perforation;

however, the true incidence of unretrieved stones is difficult to

determine. In addition to stone spillage after gallbladder rupture,

spillage may occur during forced delivery of a freed, tense gallbladder

through a narrow umbilical port orifice.

Jakimowicz[11] reported a 0.1% to 0.3% incidence of unretrieved stones; 8%

of these patients developed complications related to the missed stones.

Targarona and colleagues[9] reported gross spillage of stones in 5

patients, 1 of whom developed complications.

In our series of 1257 patients who underwent laparoscopic cholecystectomy

performed by a single surgeon at Mersin State Hospital, an intraoperative

perforation of the gallbladder was noted in 11.6% of cases and spillage of

stones was seen in 3.6%. We made an effort to retrieve the spilled stones

but could not determine the number of unretrieved stones in each case. The

2 major complications related to spilled stones, as mentioned previously,

were small bowel obstruction and abdominal wall abscess.

More recently, an increasing number of case reports have been published

concerning complications related to spilled stones. These complications

include intra-abdominal abscesses[6-8,12] and abdominal wall

abscesses.[13-17] Other complications involve stones that have migrated

into the ovary,[18] through the retroperitoneum to a previous surgical

wound,[19] or to the chest and onto the pleura.[20] Cullis and others[21]

reported a small bowel obstruction secondary to a gallstone abscess.

In our first patient, the complication occurred early after laparoscopic

cholecystectomy, and there was no abscess formation. The foreign body

response was severe, possibly because of the sharp-edged fragments of

stones. The body tends to discharge stones lost in the abdominal cavity

through previous surgical wounds or port sites. Abscesses form at the site

where the stones attempt to pass through the abdominal wall.

In our second patient, for whom we performed a simple drainage of the

abscess without removing all stones, a fistula with intermittent drainage

resulted.[7,15,17]

Conclusions

In most instances, operation is required for the treatment of complications

of spilled stones. We believe that stones left in the abdominal cavity are

a potential danger, and every effort should be made to recover all stones

that are spilled at the time of laparoscopic cholecystectomy. Open

retrieval should be considered in selected cases if large stones or a large

number of stones are lost.