Digestive complications of gallstones lost during laparoscopic cholecystectomy

Abstract

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 4×6-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.

Introduction

During laparoscopic cholecystectomy (LC), the gallbladder is perforated during its detachment from the liver or during its extraction through the trocar site in up to 40% of cases, especially if the indication for LC is acute cholecystitis ¹,²,³,⁴,⁵. In 30% of LCs, gallstones are dropped into the peritoneal cavity around the liver, on the omentum, between small bowel loops or into the abdominal wall, and in 20% of LCs dropped gallstones are not removed because of their number, their fragmentation and their location ¹,²,³,⁴,⁵. Experimental studies have shown that lost gallstones can induce adhesions, inflammatory reactions, abscesses or peritonitis, especially if they are large, pigmented, numerous, fragmented, infected or associated with infected bile ⁶,⁷,⁸,⁹,¹⁰. Surgical series have shown that complications related to lost gallstones occur in 0.5–6% of LC ¹,²,³,⁴,⁵.

Case report

A 75-year-old man was admitted with epigastric pain, vomiting and constipation. Eight years earlier, he had undergone LC because of acute cholecystitis. The gallbladder was extracted through the umbilical trocar site, but the large stone in the gallbladder was not removed. On admission, the abdomen was distended, tympanitic and painful. There was no fever and no leucocytosis. Abdominal X-ray showed two distended small bowel loops. Ultrasound scan showed distended small bowel loops above an intraluminal echo-dense object. CT scan showed diffuse distension of the small bowel and an inflammatory adhesion of a small bowel loop to the anterior abdominal wall (Figure 1), but the echo-dense object was not identified at the junction between distended and non-distended small bowel loops. With nasogastric suction, the abdominal pain resolved and the patient had a bowel action. The following day, the abdominal X-ray showed increasing distension of the small bowel loops, and a contrast X-ray showed jejunal distension above an angulation (Figure 2) plus ileal distension above a well-defined luminal object (Figure 3).

Figure 1. .

CT scon: right-sided inflammatory adhesion of a small bowel loop to the anterior abdominal wall at the site of the Meckel's diverticulum.

Figure 2. .

Small bowel series: angulation ofthe jejuno-ileal junction at the site of the Meckel's diverticulum. Jejunal loops located in the sub-diaphragmatic area are dilated.

Figure 3. .

Small bowel series: an intraluminal object located in the right iliac fossa is well delineated with a convex proximal extremity and a tubular body.

The diagnosis of intestinal obstruction above an intra-ileal stone was made, and the patient was operated through a midline laparotomy. The jejunum was distended at its junction with the ileum above an angulated loop of bowel adherent to the right upper abdominal wall. Once this adhesion was detached, a Meckel's diverticulum was found at 1 metre from the ileocaecal valve, with a thickened wall, a wide base, a tight fibrous adhesion fixing its tip to the abdominal wall and perforation of this tip into the abdominal wall through an omental defect. The ileum was distended above an intraluminal calculus, 4×6 cm in diameter, located 15 cm above the caecum. The stone was extracted through the base of the Meckel's diverticulum, which was removed.

Histological analysis showed an ulcerated and infected Meckel's diverticulum without metaplasia. Chemical analysis of the stone showed that it contained 82% cholesterol, but no bile salts; its nucleus was pigmented and rich in cholesterol. The appearance of the stone, its fragmented distal extremity, its yellow-brown colour, its radial structure (Figure 4) and its chemical composition indicated that it was a gallstone.

Figure 4. .

The causative gallstone, (a) The body of the gallstone is tubular, its proximal extremity (on the right side) is hemispherical but its distal extremity (on the left side) was found to be broken, (b) At the level of the broken distal extremity, the internal structure of the gallstone is observable. This extremity had been broken 8 years before during LC. (c) Radiography of the gallstone shows minimal calcium deposits on its surface and on the broken extremity.

The calculus that had been left behind in the abdominal cavity during LC caused a chronic inflammatory reaction, passed through the omentum, perforated the tip of the Meckel's diverticulum and penetrated into its lumen, finally migrating along the lumen of the ileum to cause a gallstone ileus 8 years after LC.

Discussion

Gallstones lost during LC can remain close to the gallbladder bed or migrate into the peritoneal cavity ¹,²,³,⁴,⁵. They may be found under or in the liver, under the diaphragm, in the Rutherford Morrison's pouch, in the right paracolic gutter, between small bowel loops, on the omentum, in a hernial sac, in the pouch of Douglas or in a trocar site. In between 1% and 30% of such cases, or in 0.5–6% of LCs, the dropped stones lead to a pseudo-tumoural inflammatory reaction, an abscess or a generalised peritonitis ¹,²,³,⁴,⁵. If the abscess and the stone are near to or within a trocar site, they can be evacuated through it. If they are posteriorly placed, they can migrate and evacuate through the posterior abdominal wall. If they are subphrenic in site, they can perforate the diaphragm and migrate into the pleural cavity giving empyema and pleurolithiasis, or into the bronchial tree giving haemoptysis or even lithoptysis (i.e. the stone is coughed up). If they lie close to the urinary tract, they can migrate into the ureter and bladder. If they lie in the pouch of Douglas, they can migrate into the ovaries or the uterus.

In 12 published cases, missing stones in contact with the alimentary canal were responsible for digestive complications ²,⁷,¹¹,¹²,¹³,¹⁴,¹⁵,¹⁶,¹⁷,¹⁸. The inflammatory reaction, the abscess and the stones can compress the bowel to cause an intestinal obstruction ¹¹,¹⁵,¹⁶,¹⁷,¹⁹. They can perforate the bowel wall to cause a communicating abscess ²,⁷,¹²,¹³,¹⁴,¹⁵,¹⁶,¹⁷,¹⁸ that can also drain through a trocar site causing an enterocutaneous fistula ²,¹⁴, or into the bladder causing an enterovesical fistula ¹². Through the perforation in the wall of the bowel, the calculus can migrate in the lumen of the bowel to be eliminated in the stools. However, a large calculus may become obstructive above the ileocaecal valve or at the site of an anastomosis causing gallstone ileus ²,⁷,¹³,¹⁸.

Meckel's diverticulum has never been involved in gallstone ileus caused by stones either spilled during LC or migrating from a gallbladder through a cholecystoenteral fistula. In the present case, the inflammatory reaction surrounded the Meckel's diverticulum and part of the omentum. The calculus perforated the omentum and then the tip of the Meckel's diverticulum, which was used as a pathway to reach the lumen of the small bowel. The calculus became obstructive when it reached the last ileal loop.

Patients with retained stones in the abdominal cavity may either remain asymptomatic until a complication occurs or develop fever and abdominal pain immediately after LC. The pain varies in intensity, location and duration, lasting for a few days ¹,⁷,¹⁴,¹⁹ or recurring over several months ¹,¹¹,¹³. Complications can occur up to 3 years after LC ¹. An inflammatory reaction simulates a tumour of the abdominal wall or abdominal cavity. Intraperitoneal abscess causes abdominal pain, fever, chills, anorexia, weight loss, gynaecological disorders, swelling and guarding. Intestinal obstruction either from gallstone ileus ²,⁷,¹³,¹⁸ as in the case described here, or because of the compression of a small bowel loop ¹¹,¹⁵,¹⁶,¹⁷,¹⁹ causes abdominal colic, vomiting and constipation. Enterocutaneous or enter-ovesical fistula causes discharge of stones and intestinal contents through the abdominal wall or into urine ²,¹²,¹⁴.

The diagnosis of digestive complications of retained gallstones is difficult because 1) the delay between LC and complication is long and variable, 2) the clinical features are variable, and 3) the patient does not usually know that a stone has been left in the peritoneal cavity; this situation is not always mentioned in the operation record. Even if imaging is operator-dependent, it is easier to interpret if the radiologist is looking specifically for a missing gallstone ¹,¹². Radiolucent stones will not be seen on abdominal X-ray ¹,¹⁶. Ultrasound scans may show stones that are >1 cm in diameter, agglutinated or not located between small bowel loops ¹,¹⁵,¹⁸,¹⁹. An inflammatory reaction or abscess surrounding the stones may also be apparent. In patients with gallstone ileus or intestinal obstruction, the scan will show dilated small bowel loops. Contrast X-rays may help to demonstrate a communicating abscess or fistula and to identify the location and cause of the obstruction ¹⁸. While MRI will show all stones ²⁰, CT scan may only show those that are radio-opaque ¹²,¹⁵,²⁰. Both modalities demonstrate the inflammatory reaction or abscess surrounding the retained stones plus any extension into the peritoneum, retroperitoneum, abdominal wall or thorax.

The treatment of gallstones lost during LC depends on the type of complication but will always include draining the abscess and removing all calculi. Digestive complications may necessitate intestinal resection ⁷,¹³,¹⁴,¹⁶, enterotomy to remove an intraluminal stone ¹⁸, enterolysis ¹¹,¹⁹, suture of intestinal perforation ¹⁵, intestinal bypass ¹⁷ or colonoscopy to remove a paracolic stone that has perforated the colon ¹². In the present case, once adhesiolysis was completed, the calculus was removed through the wide base of the Meckel's diverticulum, which was then removed. Thus a direct operation on the ileum was unnecessary.

Knowledge of the incidence and potential severity of these problems should encourage the surgeon to avoid dropping gallstones during LC. The gallbladder is easily opened during dissection if its wall is thin, if it is under tension, infected, gangrenous or incarcerated in the liver. A vulnerable gallbladder should be punctured and manipulated with non-traumatic instruments. If the gallbladder is opened during dissection, it can be sutured, but such sutures can tear during subsequent traction. To avoid their intraperitoneal dispersion, the stones can be removed from the gallbladder and placed in an intraperitoneal bag that is removed at the end of the procedure ¹,²,³,⁴,⁵. During extraction in a protecting bag, the trocar site should be enlarged to avoid rupture of the bag and the gallbladder.

If stones are dropped into the peritoneum, they have to be removed laparoscopically ¹,⁴, especially if they are pigmented, large, numerous, fragmented, infected or associated with infected bile ⁶,⁷,⁸,⁹,¹⁰. Conversion to laparotomy to remove the missing stones is one option but it increases the incidence of postoperative complications ⁴. The peritoneal cavity should be washed extensively and antibiotic therapy should be administered postoperatively because infection is the most frequent postoperative complication ¹. The incident should be mentioned in the operation note and the patient should be informed. Thereafter, the patient should be kept under clinical review with ultrasound scans to localise the lost stone(s) and detect any complication.