Reformed gallbladder after laparoscopic subtotal cholecystectomy: correlation of surgical findings with ultrasound and CT imaging

Abstract

Laparoscopic subtotal cholecystectomy is a technique that is becoming increasingly prevalent in modern surgery. It avoids the cystic duct and artery where acute or chronic cholecystitis prevents a safe laparoscopic dissection of these structures. There are numerous reports of symptomatic cystic duct remnants after subtotal cholecystectomy in the literature on post-cholecystectomy syndrome. We present a case report of a 62-year-old man who underwent emergent laparoscopic subtotal cholecystectomy complicated by the development of a persistent, controlled bile leak. This was followed on serial ultrasound examinations and managed with multiple drain insertions and endoscopic retrograde cholangiopancreatography. The patient represented 4 months later with right upper quadrant pain and was found to have an apparently normal gallbladder on CT abdomen. Repeat laparoscopic cholecystectomy demonstrated a reformed gallbladder wall and was completed in the standard fashion. This case demonstrates an unexpected complication of laparoscopic cholecystectomy with correlation of radiological and surgical findings.
Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2015.

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CASE REPORT
Reformed gallbladder after laparoscopic subtotal
cholecystectomy: correlation of surgical findings
with ultrasound and CT imaging
†
Suzanne J. Di Sano* and Nicholas B. Bull
Department of Surgery, Gosford Hospital, Gosford, NSW, Australia
*Correspondence address. Gosford Hospital, NSW 2250, Australia. Tel: +61-432-967-477; Fax: (02) 4320 2808; E-mail: suzanne.disano@gmail.com
Abstract
Laparoscopic subtotal cholecystectomy is a technique that is becoming increasingly prevalent in modern surgery. It avoids
the cystic duct and artery where acute or chronic cholecystitis prevents a safe laparoscopic dissection of these structures.
There are numerous reports of symptomatic cystic duct remnants after subtotal cholecystectomy in the literature on post-
cholecystectomy syndrome. We present a case report of a 62-year-old man who underwent emergent laparoscopic subtotal
cholecystectomy complicated by the development of a persistent, controlled bile leak. This was followed on serial ultrasound
examinations and managed with multiple drain insertions and endoscopic retrograde cholangiopancreatography. The patient
represented 4 months later with right upper quadrant pain and was found to have an apparently normal gallbladder on CT
abdomen. Repeat laparoscopic cholecystectomy demonstrated a reformed gallbladder wall and was completed in the standard
fashion. This case demonstrates an unexpected complication of laparoscopic cholecystectomy with correlation of radiological
and surgical findings.
INTRODUCTION
Open su btotal c hol ecystectomy was first described in 1985 by
Bornman and Terblanche [1]. The procedure was later adapted
in 1993 to the laparoscopic technique [2, 3]. There are three
described methods that may avoid dissection of the triangle of
Calot. Type 1 involves transection at the neck of the gallbladder
wit h no dissection or ligation of the cystic duct or artery and a
sutured closure of the proximal stump. Type 2 leaves the hepatic
aspect of the gallbladder wall intact. Type 3 involves a combin-
ation of the first two techniques [4, 5]. On completion of the sub-
total cholecystectomy, regardless of the type, there is extensive
cauterization of any residual gallbladder mucosa.
Subtotal cholecystectomy is primarily utilized in the setting
of significant acute or chronic cholecystitis as it avoids potentially
unsafe dissection and subsequent trauma to the biliary tree and
adjacent structures.
Within the literature on the post-cholecystectomy syndrome,
there a re multiple articles and c ase reports documenting the
presence of cystic duct remnants after subtotal cholecystectomy,
some of which develop calculi [2, 6]. We present a case study of
‘reformed gallblad der ’, wherein the gallbladder remnant after
subtotal ch olecystectomy has been followed with serial ultra-
sound exa mination. It formed a distinct compartment, which
strongly resembles a nor mal gallbladder on interval CT scan,
and required repeat laparoscopic cholecystectomy.
†
To our knowledge, this is the first correlation of radiological and intraoperative findings in reformed gallbladder after subtotal cholecystectomy and we
believe it would appeal to the readership of the Journal of Surgical Case Reports. This manuscript has not been published and is not currently submitted for
review by any other journal or publishing body.
Received: September 24, 2014. Accepted: December 29, 2014
Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2015.
This is an Open Access article distributed under the te rms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any me dium, provided the original work is properly cited.
For commercial re-use, please contact journals.permissions@oup.com
Journal of Surgical Case Reports, 2015 , 1–3
doi: 10.1093/jscr/rju154
Case Report
1
; 2

CASE REPORT
A 62-year-old man presented to the emergency department with
3 weeks of intermittent right upper quadrant pain. CT of the ab-
domen demonstrated acute ch olecystitis complicated by a con-
tained perforation of the gallbladder at the hepatic aspect.
A Type 3 laparoscopic subtotal cholecystectomy was performed
the day after his admission due to an inability to safely dissect in-
flammatory adhesions, which held the duodenum in close prox-
imity to the structures of Calot’s tri angle. The remaining
gallb ladder tissue was diathermied and a drain was placed in
the gallbladder fossa.
This patient remained in hospital for 1 month with post-
operative complications. Ongoing leakag e of bile prompted
insertion of a percutaneous drain and endoscopic retrograde cho-
langiopancreatography with stent insertion. Ultrasound of the
abdomen performed on Day 14 postoperatively demonstrated a
collection with lobulated margins (Fig. 1). Concurrent hepatobili-
ary iminodiacetic acid scan confirmed that this represented an
ongoing bile leak contained within the gallbladder fossa.
Further ultrasound studies on Days 21 and 31 demonstrated
an ongoing or ganizing collection (Fig. 1). He was discharged
wi th the p ercutaneous drain in place, which was removed on
Day 37 when drainage eventually ceased.
The patient presented to the hospital 4 months after the ini-
tial operation with right upper quadrant pain. CT abdomen estab-
lished the appearance of a normal gallbladder despite his history
of subtotal cholecystectomy (Fig. 2). He underwent an elective
laparoscopic cholecystectomy 1 month later, which revealed an
apparently complete gallbladder that was extensively walled
off by omentum. An intraoperative image is shown in Fig. 3.
The postoperative recovery was uneventful and t he patient
remained pain and gallbladder free. Acute on chronic cholecyst-
itis and contiguous gallbladder mucosa were demonstrated by
histopathological analysis.
DISCUSSION
This study presents radiological correlation of an interesting sur-
gical case. The progressive ultrasound images demonstrate or-
ganization and localization of a postoperative collection, which
is later indistinguishable from normal biliary anatomy on CT.
This finding is confirmed intraoperatively.
At present, there is little long-term data available document-
ing the rate of complicat ions of subtotal cholecystectomy, and
studies currently available are often of retrospective design
and have small sample sizes [2]. As laparoscopic subtotal chole-
cystectomy i ncreases in popularity (and open conversions
subseq uently decline), this case demonstrates potential for an
unexpected postoperative outcome. Additionally, it h ighlights
that further imaging may be quite useful in patients with recur-
rent symptoms following subtotal cholecystectomy.
CONFLICT OF INTEREST STATEMENT
None declared.
Figure 1: Ultrasound on postoperative Days 14 (left), 21 (middle) and 31 (right). Liver is on the left in each image, and the persistent collection is demonstrated within the
gallbladder fossa.
Figure 2: An axial CT image shows collection in the gall bladder fossa closely
resembling a normal gallbladder appearance.
Figure 3: Intraoperative image of H artmann’s pouch (held by graspers) in
continuity with a reformed gallbladder.
2 | Reformed gallbladder after laparoscopic subtotal cholecystectomy

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