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CT scans of the abdomen and pelvis, demonstrating multiple hyperdense soft tissue nodules mimicking peritoneal metastases.
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Spillage of bile and gallstones due to accidental perforation of the gallbladder wall is often encountered during laparoscopic cholecystectomy. Although spilled stones were once considered harmless, there is increasing evidence that they can result in septic or other potential complications.
We report a case of spilled gallstones mimicking peritone...
Context in source publication
Context 1
... markers (CEA, CA-125, CA 19.9) were within the normal range. Contrast enhanced CT scan of the abdomen and pelvis was repeated; this revealed multiple, round hyperdense soft tissue nodules (the largest measuring 18mm x 9mm in size) within the abdominal cavity suggestive of mesenteric lymphadenop- athy and peritoneal metastases (Figure 1). CT colography and upper GI endoscopic examinations were normal. ...Similar publications
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Citations
... In 8 (7.8%) cases the lost gallstones mimicked malignancy. Lost gallstones may either mimic peritoneal carcinomatosis or the presence of a primary tumor, leading to excision (7,22,25,32,61,84,86). Remarkable 66.6% (n = 68) of the patients required open surgical procedures, 17.6% (n = 18) laparoscopic revisions and 12.7% (n = 13) were treated with ultrasound or CT guided drainage. ...
Introduction
Laparoscopic cholecystectomy (LC) represents one of the most commonly performed routine abdominal surgeries. Nevertheless, besides bile duct injury, problems caused by lost gallstones represent a heavily underestimated and underreported possible late complication after LC.
Methods
Case report of a Clavien-Dindo IVb complication after supposedly straightforward LC and review of all published case reports on complications from lost gallstones from 2000-2022.
Case Report
An 86-year-old patient developed a perihepatic abscess due to lost gallstones 6 months after LC. The patient had to undergo open surgery to successfully drain the abscess. Reactive pleural effusion needed additional drainage. Postoperative ICU stay was 13 days. The patient was finally discharged after 33 days on a geriatric remobilization ward and died 12 months later due to acute cardiac decompensation.
Conclusion
Intraabdominal abscess formation due to spilled gallstones may present years after LC as a late complication. Surgical management in order to completely evacuate the abscess and remove all spilled gallstones may be required, which could be associated with high morbidity and mortality, especially in elderly patients. Regarding the overt underreporting of gallstone spillage in case of postoperative gallstone-related complications, focus need be put on precise reporting of even apparently innocuous complications during LC.
... granulomatous peritoneal reactions, sometimes mimicking peritoneal seeding [1][2][3][4][5]. ...
... As mentioned above, laparoscopic cholecystectomy is the gold standard procedure in the management of symptomatic gallstone disease, and it is associated with relatively mild complications. To our knowledge, bile or gallstone spillage during laparoscopic cholecystectomy occurs in 13% to 40% of cases because of gallbladder perforation during surgical dissection and extraction because of an oedematous, friable or gangrenous wall, depending on the surgeon's expertise [1]. The primary strategy to prevent dropped gallstones is surgical removal of an intact gallbladder, by means of careful dissection and aspiration of bile from a tense gallbladder. ...
... In case of gallstones spilled into the abdominal cavity, all the accessible stones should be retrieved using additional ports, 30° telescopes, pressure injection, shuttle collectors and copious irrigation to reduce contamination and facilitate further stone removal. Conversion to open surgery after accidental perforation of the gallbladder and spillage is not routinely recommended [1,2]. ...
Bile or gallstone spillage during laparoscopic cholecystectomy occurs in 13 to 40% of cases of surgical dissection and extraction of a very inflamed gallbladder with friable or gangrenous walls. We present a case of a patient who developed a biliary granulomatous peritoneal reaction as consequence of cholecystectomy for acute-on-chronic cholecystitis. Our patient, after about 2 years from the surgery, in the follow-up imaging studies, showed multiple nodules disseminated in the peritoneal cavity suggestive for malignancy both on abdomen computer tomography scan and on positron emission tomography. Thus, laparoscopic nodulectomy lastly allowed the histologic diagnosis of biliary peritoneal granulomatous reaction. Even with benign assessment of nodules’ nature, these lesions showed a progressive trend of increasing over time in number and dimensions. We performed PubMed research of all cases reported in the literature to examine the cases features and to compare our findings with other clinical experiences reported by eleven international canters. Many patients were completely asymptomatic; as an occasional finding mimicking peritoneal seeding, further assessment to define the benign nature of these nodules were performed, so they underwent surgical treatment. The development of multiple abdominal nodules resulting from a foreign-body granulomatous reaction to bile/gallstones is a quite rare event after laparoscopic cholecystectomy, but we believe it should be seriously considered in patients who have undergone complicated surgical procedures on biliary tracts.
... In case of gallstones spilled into the abdominal cavity, all the accessible stones should be retrieved using additional ports, 30° telescopes, pressure injection, shuttle collectors and copious irrigation to reduce contamination and facilitate further stone removal. Conversion to open surgery after accidental perforation of the gallbladder and spillage is not routinely recommended 1,2 However, despite the usual complete retrieval of spilled gallstones, 2.4% of LC is complicated by unretrieved intra-abdominal gallstones, which can cause abscesses; the treatment is based on the complete removal of gallstones and drainage of pus. These procedures can be performed interventional, laparoscopically, thoracoscopically or by open approach. ...
Introduction: Bile or gallstone spillage during laparoscopic cholecystectomy occurs in 13 to 40% of cases of surgical dissection and extraction of very inflamed gallbladder with friable or gangrenous walls.
Case presentation: We present a case of a patient who developed this rare complication after a difficult cholecystectomy for acute-on-chronic cholecystitis. Our patient, after about 2 years from the surgery, in the follow-up imaging studies, showed multiple nodules disseminated in the peritoneal cavity suggestive for malignancy both on abdomen computer tomography scan and on positron emission tomography. Thus, laparoscopic nodulectomy, lastly allowed histologic diagnosis of biliary peritoneal granulomatous reaction. Even if benign assessment of nodules’ nature, these lesions showed a progressive trend in increasing over the time in number and dimensions. We performed PubMed research of all cases reported in literature, to examine the cases features and to compare our findings with other clinical experiences reported by eleven international canters. Many patients were completely asymptomatic; as an occasional finding mimicking peritoneal seeding, further assessment to define the benign nature of these nodules were performed, so they underwent surgical treatment.
In conclusion, development of multiple abdominal nodules resulting from a foreign-body granulomatous reaction to bile/gallstones is a quite rare event after laparoscopic cholecystectomy, but we believe it should be seriously considered in patients undergone complicated surgical procedures on biliary tracts.
... Out of that, 2 cases (2%) were associated with spilt gallstones, which is ~ 572 ~ in accordance with studies published by others Studies show that the most common complications after spilt and retained calculi in the abdominal cavity are: intra-abdominal abscesses, fistulas, and tumefactions of the abdominal wall [31,33] . Dasari BVM et al. [32] reported spilt calculi in 19.8% laparoscopic cholecystectomies in their study. In our study, we report abscess collections during the postoperative period in 1 cases (1%). ...
... In modern laparoscopic surgery, conversion is not considered to be a complication, but instead a way for the surgeon to safely finish the surgery. Therefore, the surgeon should have a low threshold for conversion [28,32,33] . In our study, we report 9 conversions (9%). ...
... These complication rates were compared with their respective accepted standard complication rates: 10-30% for bile or stone spill without ductal injuries, 10% for bleeding 1-11% for bile leaks, which is inclusive of the level of training of the surgeon and of elective and emergency procedures, and 5-10% for conversion to open. [4][5][6][7]13 ...
Background: The aims of this audit were to determine the rate of complications of laparoscopic cholecystectomy performed by a junior surgeon, to identify changes that can be made to reduce the complications, and to re-audit the complication rate after the changes have been made.Methods: Laparoscopic cholecystectomies performed by the surgeon between August and November, 2018 were assessed retrospectively. Data was collected from electronic records and operation notes and entered in the format as enclosed within. A re-audit was conducted between December 15th, 2018 and June 15th, 2019.Results: In the initial audit, the complication rate of laparoscopic cholecystectomy was 40% and the incidence of bile leaks was 6%. The re-audit showed a significant reduction in the overall complication rate to 24% with no incidence of bile leaks.Conclusions: The learning curve of surgeons for laparoscopic procedures is steep and cases should be chosen carefully depending on the current skill set and comfort level of the surgeon. Recommended standard practices should be followed in all situations, and all the team members should be involved in identifying risks during the surgery.
... Wedge resection of the liver and right diaphragm Papadopoulos et al. [31] Gallstones embedded in the omentum Removal during right hemicolectomy Rammohan et al. [32] Subphrenic abscess Laparoscopic drainage Kayashima et al. [33] Inflammatory pseudotumor of the liver Posterior segmentectomy combined with partial resection of the diaphragm Pottakkat et al. [34] Dumbbell-shaped abscess in the perihepatic area Open exploration and abscess drainage Hussain et al. [35] Abdominal wall abscess and discharging sinus Incision drainage and secondary closureof the wound Gooneratne et al. [36] Colovesical fistula Repair of the colovesical fistula Bouasker et al. [37] Subcutaneous collection Drainage of a collection containing a large stone Morishita et al. [38] Granuloma Conservative therapy Helme et al. [39] Abscess US-guided drainage Dasari et al. [40] nodules mimicking peritoneal metastases Laparoscopic viscerolysis Maempel et al. [41] Abdominal wall abscess Incision and drainage of abscess Arishi et al. [42] Cystic mass of the rectus abdominis Surgical removal Hougard et al. [43] Fistula of the abdomen Excision of fistula Stupak et al. [44] Subhepatic collection Percutaneous drainage De Hingh et al. [45] Rectovaginal pouch abscess Surgical removal Pantanowitz et al. [46] Left ovary granuloma (cervical cancer) Surgery (hysteroannessiectomy) Wehbe et al. [47] Mass in the right lower quadrant Laparoscopic removal Wittich et al. [48] Abscess in the pouch of Douglas Transvaginal hysterectomy for severe metrorrhagia and dysmenorrhea, through a colpotomy incision, 16 gallstones were discovered in the pouch of Douglas Shrestha et al. [49] Cholecystocolocutaneous fistula Excision of fistula Bhati et al. [50] Liver abscess/sub-diaphagmatic abscess/sub-diaphragmatic and right flank abscess Laparatomic excision/laparotomic excision/radiologically guided drainage ...
Introduction:
Laparoscopic cholecystectomy (LC) has become the "gold standard" for the treatment of symptomatic gallstones. However, this surgical technique increases the risk of bile duct injury and lost gallstones. Since over 90% of split gallstones never become symptomatic, they often present as incidental findings on CT-scans. Careful removal of as many stones as possible, intense irrigation and suction are recommended. It has been reported that 8.5% of lost gallstones will lead to a complication, most common are abscesses.
Presentation case:
We report a case of spilled gallstones simulating peritoneal metastases on radiological investigations. Diagnosis was very difficult, not even an US-guided biopsy of the lesion was decisive. Only a diagnostic laparoscopy confirms the diagnosis.
Discussion:
The reaction associated with lost gallstones can mimic other causes, such as soft tissue sarcoma, malignant lymphoma or, as in our case peritoneal carcinomatosis.
Conclusion:
Spilled gallstones are associated with uncommon, but significant complications, and even the diagnosis of such a condition can cause serious difficulties. Serious effort must be made to prevent gallbladder perforation, and accidental stone spillage should be promptly recognized and properly managed.
... Data and studies have been performed to create standardization of management of spilled stones recommending that conversion to open cholecystectomy is unnecessary [17]. Various techniques include use of endobag to retrieve gallbladder from ports, 30° telescopes to aid better visualization, pressure injection, copiously irrigating peritoneal cavity to reduce contamination and facilitate further stone removal and use of shuttle stone collectors [18]. However, most important aspect in the management of stone spillage and biliary spillage is documentation. ...
... [16] Some of these complications are not so significant, while some others are very significant which include abscess in the abdominal wall, broncholithiasis, stone expectoration, cellulitis, dyspareunia, erosion to the back, fat necrosis posterior of the rectus muscle, fever, fistula formation, gallstone granuloma, gluteal abscess, granulomatous peritonitis mimicking endometriosis, ileus, intestinal obstruction, implantation malignancy, incarcerated hernia, intra-abdominal abscess, jaundice, liver abscess mimicking malignancy, middle colic artery thrombosis, mimicking acute appendicitis, paracolic abscess, paraumbilical tumour, peritoneal abscess formation, pelvic abscess, pelvic stones, peritonitis, pleural empyema, fluid collections, pneumonia, port site stones, port site abscess, recurrent staphylococcal bacteraemia, retrohepatic abscess, retroperitoneal abscess, retroperitoneal actinomycosis, right flank abscess, small bowel obstruction, stones in gastrocolic omentum, stones in hernia sac, stones of the ovary, stones in the fallopian tube, subhepatic abscess, subphrenic abscess, thoracoabdominal mycosis, transdiaphragmatic abscess, umbilical wound abscess and vesicle granuloma. [3,4,16,17] In this prospective study, we have documented the late complication of spilt stones in our institution. The incidence of spilt gallstones was noted to be 18.91% in our series. ...
... Studies show that the most common complications after spilt and retained calculi in the abdominal cavity are: intra-abdominal abscesses, fistulas, and tumefactions of the abdominal wall [25][26][27]. Dasari BVM et al. [26] reported spilt calculi in 19.8% laparoscopic cholecystectomies in their study. In our study, we report abscess collections during the postoperative period in 2 cases (0.27%). ...
... Studies show that the most common complications after spilt and retained calculi in the abdominal cavity are: intra-abdominal abscesses, fistulas, and tumefactions of the abdominal wall [25][26][27]. Dasari BVM et al. [26] reported spilt calculi in 19.8% laparoscopic cholecystectomies in their study. In our study, we report abscess collections during the postoperative period in 2 cases (0.27%). ...
... In modern laparoscopic surgery, conversion is not considered to be a complication, but instead a way for the surgeon to safely finish the surgery. Therefore, the surgeon should have a low threshold for conversion [14,26,27]. In our study, we report 29 conversions (3.91%). ...
AIM: The aim of this study was to evaluate the intraoperative and postoperative complications of laparoscopic cholecystectomy, as well as the frequency of conversions.
MATERIAL AND METHODS: Medical records of 740 patients who had laparoscopic cholecystectomy were analysed retrospectively. We evaluated patients for the presence of potential risk factors that could predict the development of complications such as age, gender, body mass index, white blood cell count and C-reactive protein (CRP), gallbladder ultrasonographic findings, and pathohistological analysis of removed gallbladders. The correlation between these risk factors was also analysed.
RESULTS: There were 97 (13.1%) intraoperative complications (IOC). Iatrogenic perforations of a gallbladder were the most common complication - 39 patients (5.27%). Among the postoperative complications (POC), the most common ones were bleeding from abdominal cavity 27 (3.64%), biliary duct leaks 14 (1.89%), and infection of the surgical wound 7 patients (0.94%). There were 29 conversions (3.91%). The presence of more than one complication was more common in males (OR = 2.95, CI 95%, 1.42-4.23, p < 0.001). An especially high incidence of complications was noted in patients with elevated white blood cell count (OR = 3.98, CI 95% 1.68-16.92, p < 0.01), and CRP (OR = 2.42, CI 95% 1.23-12.54, p < 0.01). The increased incidence of complications was noted in patients with ultrasonographic finding of gallbladder empyema and increased thickness of the gallbladder wall > 3 mm (OR = 4.63, CI 95% 1.56-17.33, p < 0.001), as well as in patients with acute cholecystitis that was confirmed by pathohistological analysis (OR = 1.75, CI 95% 2.39-16.46, p < 0.001).
CONCLUSION: Adopting laparoscopic cholecystectomy as a new technique for treatment of cholelithiasis, introduced a new spectrum of complications. Major biliary and vascular complications are life threatening, while minor complications cause patient discomfort and prolongation of the hospital stay. It is important recognising IOC complications during the surgery so they are taken care of in a timely manner during the surgical intervention. Conversion should not be considered a complication.
... The lesson from this case is that lost stones should be retrieved at the time of surgery [3][4][5]. 40% of laparoscopic cholecystectomies the gold standard treatment of gallstones have a varying degree of stone spillage [5,6]. In most patients no complications occur [3]. ...
... In most patients no complications occur [3]. The incidence of complications is low enough however that conversion to laparotomy is not justified for stones that are not retrievable laparoscopically [6]. Caution should therefore be exercised during dissection of the gallbladder to avoid perforating the gallbladder in the first instance. ...
... Complications can be compounded further if there is incidental gallbladder carcinoma (0.6-2.1%) on histology as spilled tumour bedded stones could potentially cause disease recurrence if not removed [3]. It is therefore essential that any cholecystectomies whether total or subtotal with gallstone leakage is well documented and that this is clearly highlighted in the patients past surgical history under the named procedure [6]. This ensures effective communication between colleagues so all are aware of the previous morbidity. ...
