Laparoscopic management of intra-hepatic gallbladder perforation

Abstract

Intra-hepatic perforation of the gallbladder (GB) leading to hepatic abscess is a serious and rare complication of cholecystitis, with very few sporadically reported cases in the literature. Hence, there is no standard approach to treat it. A thorough radiological evaluation with computed tomography and endoscopic retrograde cholangiopancreatography is necessary before proceeding with surgery in such cases. An early laparoscopic intervention to perform a sub-total cholecystectomy with drain placement is enough to treat both cholecystitis and liver abscess in a definitive manner. While previous reports have advocated an open surgery, our series demonstrates that early laparoscopic management is a safe and suitable approach in such cases.

INTRODUCTION

Gallbladder (GB) perforation is a rare complication of acute cholecystitis. It remains a diagnostic dilemma to surgeons and is associated with a significant morbidity and mortality risk.[1] Concomitant GB perforation along with hepatic abscess formation is also known as intra-hepatic GB perforation. This creates a cholecystohepatic fistula which is extremely rare, with only sporadic cases being reported in literature. We report two cases which were successfully treated with early laparoscopic surgery.

CASE REPORTS

Case 1

A 55-year-old male presented to us with pain in right hypochondrium and fever for 10 days. He was a known case of rheumatoid arthritis on immunosuppressive therapy. Ultrasound was suggestive of thickened GB wall with pericholecystic collection. Computed tomography (CT) scan revealed intra-hepatic rupture of calculus cholecystitis with a 4-cm cavity in the liver (segment V) [Figure 1a]. There was an obstructive calculus at ampulla for which endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct (CBD) stenting were done. The patient was prepared for early laparoscopic cholecystectomy the following day.

Figure 1.

(a) Computed tomography showing segment V liver abscess contiguous with gallbladder, (b) adhesions between liver and right dome of diaphragm, (c) breach in the cystic plate, and (d) liver abscess seen through the gallbladder fossa

The initial survey revealed adhesions between diaphragmatic surface of the liver and right dome of diaphragm with thinned out liver tissue in that region (segment V) [Figure 1b]. The frozen Calot's was meticulously dissected and critical view of safety demonstrated. While separating the GB off the GB fossa, the posterior (hepatic) surface of GB ruptured through cystic plate into liver parenchyma. The cystic plate was breached at three sites with largest defect around 2 cm [Figure 1c]. The cavity contained bile-stained necrotic tissue, almost extending up to the diaphragmatic surface of liver at site of adhesions. Sub-total cholecystectomy was preformed, a thorough lavage of abscess cavity was done and remainder of posterior GB wall mucosa was cauterised [Figure 1d]. A tube drain was placed in Morrison's pouch.

Case 2

A 28-year-old female patient was brought to the emergency department with worsening biliary colic. She was recently found to have an impacted CBD stone, for which ERCP and CBD stenting were done. Check ultrasound was suggestive of acute cholecystitis with possible rent in the GB wall with an adjacent liver abscess. CT scan confirmed the findings and additionally revealed a replaced right hepatic artery arising from superior mesenteric artery [Figure 2a].

Figure 2.

(a) Computed tomography image demonstrating the cysto-hepatic communication, (b) tense segment V of liver as seen from the anterior surface, (c) abscess cavity being entered while dissecting gallbladder off the fossa, and (d) liver abscess through the gallbladder fossa

The patient was prepared for emergency laparoscopic cholecystectomy. The GB was thick walled, distended with tense segment IV and V of the liver with purulent peritonitis of surrounding area [Figure 2b]. A retro-infundibular window was created. There was a large perforation in the intra-hepatic surface of the GB in region of the fundus–body junction communicating with a cavity in the liver [Figure 2c]. It contained thick viscid pus and slough. The culture of this pus later showed growth of Klebsiella pneumoniae. GB was transected at infundibulum and the stone in Hartmann's pouch was extracted [Figure 2d]. The GB was closed with intra-corporeal, interrupted 2-0 polyglactin sutures.

The rest of the procedure was same as the previous case. Both the patients had uneventful and brief convalescence and are doing well at 1-year follow-up.

DISCUSSION

An intra-hepatic GB perforation with abscess formation is a rare medical entity, with sporadic cases being reported in the literature. The other terms used to describe it are intra-hepatic abscess, cholecystohepatic fistula, or intra-hepatic bilioma and are classified as Type II perforation as per the Niemeier classification.[2]

Although ultrasonography is the initial investigation of choice, CT is a better and more sensitive modality for diagnosing a perforation.[3] It is also helpful in delineating anatomy pre-operatively as demonstrated in above case where the anomalous vascular anatomy was detected. In both our cases, we did a thorough routine and radiological work-up to establish a definite diagnosis. ERCP was used in both the cases to obtain adequate biliary drainage pre-operatively. In Case 2, liver abscess formation could be attributed to septic complication of ERCP.

In both our cases, CBD obstruction was probably the primary mechanism for the development of GB perforation. In Case 1, the fact that patient was on methotrexate (immunosuppressant) could be contributory, while in Case 2, there were rapid-onset inflammatory reaction and intra-abdominal sepsis caused by a virulent strain following the inability to remove the large CBD stone by ERCP.

When dealing with a life-threatening condition such as GB perforation compounded by liver abscess formation, early intervention is the key. Considering the safety and feasibility of laparoscopic cholecystectomy, it was preferred in both the cases. Demonstrating the critical view of safety is essential;[4] more so in a difficult GB operation as the risk of CBD injury is high. Furthermore, if the posterior GB wall is densely adherent to the cystic plate, it can be fulgurated and left in situ instead of doing a total cholecystectomy. The abscess cavity should be adequately de-roofed, given a thorough lavage, and drain should be kept under laparoscopic guidance.

The hospital stay in both the cases was relatively short which is an inherent benefit of minimally invasive surgery. Early laparoscopic cholecystectomy is shown to have a significantly shorter hospital stay and similar surgical outcomes when compared to percutaneous drainage followed by interval cholecystectomy.[5] In retrospect, intra-operative cholangiography could have been performed in both our cases. It would have ruled out any communication of biliary tree with the abscess cavity and confirmed the safety of the biliary tract.

Hussain et al.[6] in their recent review of intra-hepatic GB perforation with liver abscess have concluded that initial management can be conservative followed by interval cholecystectomy. Donati et al.[7] suggest that such a presentation should be dealt with early conversion or open cholecystectomy altogether. Our study successfully demonstrates the utility of laparoscopy in intra-hepatic GB perforation and its ability to treat the disease as well as its complication in the same setting.

CONCLUSION

An early laparoscopic intervention to perform a sub-total cholecystectomy with drain placement is adequate to treat both cholecystitis and liver abscess in a timely manner. Hence, it can be a definitive and standard management option for intra-hepatic GB perforation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.