Abstract
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.
1 Introduction
Gallstone disease affects up to 20% of the European population. Laparoscopic cholecystectomy (LC) is indicated in patients with symptomatic gallstones, acute cholecystitis or biliary sludge and represents one of the most commonly performed abdominal surgeries (1).
Perforation of the gallbladder is relatively common in LC and is reported in various studies to range between 10% to 40% of procedures. Gallstone spillage is less common, and the true frequency of unremoved stones is difficult to determine. Some case series indicate a range of 6% to 30% (2). Incidence increases if the surgery is performed for acute cholecystitis. Other risk factors include male sex, higher age, obesity and the presence of postoperative adhesions. Complications resulting from these spilled stones are reported to occur in 0.08% to 0.3% of patients, and most of these lost stones remain clinically silent (2).
However, even if dropped gallstones do not cause actual postoperative harm through complications, they often are not correctly identified by imaging and can be mistaken for peritoneal lesions leading to unnecessary concern. Nevertheless, a small percentage of dropped gallstones cause actual complications of immediate or delayed (even months after surgery) clinical concern, such as abscesses and fistulas (3).
Some reports show that only half of the surgeons inform the patient when gallstones are lost during operation, less than 30% inform the general practitioner about this complication and less than a quarter of surgeons informed about this complication in the consent form handed to the patient preoperatively (4). Another part of the problem is the differentiation between intraoperative iatrogenic gallbladder perforation, spillage of gallstones, retrieved and lost gallstones. Underreporting of intraoperative gallbladder perforation is common and it is almost impossible to determine the exact number of spilled gallstones. Despite examination and rinsing, it may be impossible to assure, that all gallstones spilled into the abdomen are really retrieved.
We report a case of an elderly patient presenting with a symptomatic perihepatic abscess 6 months after LC.
2 Case report
An 86-year-old male patient presented in our surgical ward 6 months after presumed, uncomplicated laparoscopic cholecystectomy performed in May 2022 due to necrotizing cholecystitis with 15 kg of weight loss, anorexia and rapid feeling of fullness since the operation. The patient denied pain or fever. Upon physical examination, the patient reported diffuse abdominal discomfort. The abdomen was described as soft with mild tenderness in the right upper abdomen. Blood tests revealed elevated C-reactive protein and white blood count. His past medical history was significant for severe tricuspid valve insufficiency, atrial fibrillation, type 2 diabetes mellitus and arterial hypertension.
Computed tomography scan (CT, Figure 1) revealed a perihepatic abscess (5.5 × 5.8 cm) with suspected connection to the pleural space and small calcareous structures. Diagnostic laparoscopy was performed. Due to a soft, vulnerable liver, small liver injuries and bleeding, open surgery was necessary to successfully and safely drain the abscess. Upon evacuation, lost gallstones were discovered and removed. Further, the diaphragm was eroded by the chronic inflammation, but the parietal pleura was intact. Follow-up x-rays revealed an increasing pleural effusion, which was considered reactive. Therefore, the placement of a chest tube in the 5th intercostal space at the midaxillary line was additionally needed and was left for 4 days. Empirical intravenous antibiotic therapy with piperacillin + tazobactam 4,000 mg/500 mg twice a day for 3 days was initiated and then switched to meropenem as a single 1,000 mg dose once every 24 h due to increasing C-reactive protein. Antibiotics were de-escalated to cefuroxime 750 mg once a day after 4 days according to the antibiogram of the detected Escherichia coli isolated from the intraoperative swab. This antibiotic regimen was followed for another 6 days.
Figure 1
Postoperative ICU stay was 13 days. Reintubation was necessary due to cardiac decompensation with pulmonary edema. In addition, acute to chronic kidney failure developed with need for hemodiafiltration. Cardiac recompensation was achieved using Levosimendan and Landiolol.
The patient was finally discharged after additional 33 days on a geriatric remobilization ward, where his autonomous ability and everyday skills were restored. However, chronic kidney failure with need for hemodialysis persisted. The patient died 12 months after being discharged due to acute cardiac decompensation.
3 Discussion
Review of the literature resulted in 211 articles, and 89 records with 102 patients (5–92) were included in the analysis (Table 1). The median age was 62 years (IQR 29–87). However, age was not reported in 6 articles. In total, there were 37 (44%) male and 47 (56%) female patients. Gender could not be determined in 18 articles. Of all 102 reports, LC was performed as emergency procedure in 33 cases (32%) (7, 13, 19, 20, 24–27, 31–36, 38, 40, 42, 43, 47, 52, 53, 60, 63, 70, 73, 79–82, 84). In 20 articles, the indication for LC was not reported. Of all 102 case reports with lost gallstones, gallstone spillage had only been recorded by the surgeon in the surgical report in 31 cases (30%). The most commonly reported symptoms of symptomatic spilled gallstones were pain (n = 58, 56.8%), fever (n = 23, 22.5%), abdominal swelling (n = 18, 17.6%), weight loss (n = 11, 10.7%) and nausea or vomiting (n = 11, 10.7%). Other symptoms were fistulation (such as bronchobiliary, colovesical or atmospheric fistulas), night sweats, changes in stool, malaise, chills, gynecological complaints and also respiratory problems such as cough, hemoptysis or dyspnoea. Furthermore, pruritus, painless jaundice, urinary tract infection or gastrointestinal reflux have been described in individual cases. In 12 patients, lost gallstones were discovered as an incidental finding in asymptomatic patients (7, 10, 11, 19, 22, 40, 47, 61, 64, 68, 84). No symptoms were reported in 11 patients. Symptom onset was reported at a median of 36 months after surgery and ranged between 1 and 180 months. Postoperative abscesses caused by spilled gallstones were reported in 60/102 (58.8%) patients. Of these, 41.1% (n = 42) were intra-abdominal abscesses, 10.7% (n = 11) abdominal wall abscesses, 7.8% (n = 8) retroperitoneal abscesses and 6.8% (n = 7) lung abscesses. 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. Only 2 (1.9%) patients were successfully treated conservatively (53, 61).
Table 1
| # | Author, country | Year | Age | Gender | Indication for LC | Reference to the spilled stones | Presenting symptoms | Time of onset of symptoms after LC | Complications caused by lost stones and location found | Type of reintervention |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | McNamee, USA (58) | 2022 | 57 | M | NR | NR | Left lower quadrant abdominal pain | Several years | Inflammatory response in left lower quadrant | Laparoscopic removal |
| 2 | Almslam, Saudi Arabia (8) | 2022 | 34 | M | NR | NR | Abdominal pain, weight loss, night sweats | 4 years | Inflammatory mass in the hepatorenal space | Robotic exploration |
| 3 | McCarley, USA (57) | 2022 | 78 | NR | NR | NR | NR | 3 months | Subhepatic abscess | Percutaneous abscess drainage |
| 4 | Waleed, USA (85) | 2022 | 44 | M | NR | NR | NR | 3 years | Peri-hepatic abscess | Open abscess-drainage with resection of portions of liver and diaphragm |
| 5 | Al-Janabi, Syria (7) | 2022 | 54 | F | Acute cholecystitis | NR | none | 10 years | Mimicking intraabdominal tumor | Omentectomy during hysterectomy with bilateral salpingo-oophorectomy |
| 6 | Al-Janabi, Syria (7) | 2022 | 29 | F | Acute cholecystitis | NR | none | 3 years | Mimicking intraabdominal implants | Resection during elective Caesarean section |
| 7 | Weeraddana, USA (86) | 2022 | 66 | F | Symptomatic cholelithiasis | NR | Right upper quadrant (RUQ) pain | 5 years | Mass in the retroperitoneum behind the hepatic flexure mimicking a retroperitoneal Tumor | Surgical removal of the mass |
| 8 | Kendera, USA (48) | 2022 | 70 | F | NR | NR | RUQ pain, occasional nausea and vomiting | 1 year | Perihepatic abscess | Percutaneous drainage |
| 9 | Tokuda, Japan (80) | 2022 | 66 | F | Acute gangrenous cholecystitis | Yes | RUQ pain, right chest pain and dyspnea | 11 months | Pleural empyema and perihepatic fluid collection | Thoracotomy and laparotomy with gallstone retrieval |
| 10 | Zeledón-Ramirez, Costa Rica (92) | 2022 | 62 | F | NR | NR | RUQ pain, feverish feeling | 3 months | Subcapsular hepatic abscess | Laparoscopic removal |
| 11 | Zeledón-Ramirez, Costa Rica (92) | 2022 | 71 | F | Elective laparoscopic cholecystectomy. | NR | Right flank pain | 6 months | Right flank abscess | Percutaneous drainage |
| 12 | Fung, USA (31) | 2022 | 69 | M | Gangrenous cholecystitis | NR | Right-lower-quadrant abdominal pain, bloody diarrhea | 5 months | Subhepatic Abscess | Laparosopic drainage |
| 13 | Kumar, USA (52) | 2022 | 86 | M | Acute cholecystitis | NR | Abdominal swelling, weight loss, nausea, emesis, loose stools | 15 years | Abdominal Wall Abscess | Percutaneous drainage |
| 14 | Hoshina, USA (41) | 2022 | 59 | F | NR | NR | RUQ discomfort | 2 years | Subdiaphragmatic abscess | Laparoscopic aspiration |
| 15 | Nagata, Japan (63) | 2022 | 73 | M | Acute cholecystitis | Yes | Fever, right chest pain, wet cough, and hemoptysis | 6 months | Lung Abscess following Subphrenic Abscess | Thoracatomy with resection of Segment VIII in the lower lobe of the right lung, abscess drainage and retrieval of the dropped gallstone |
| 16 | Danhel, Austria | 2022 | 86 | M | Necrotizing cholecystitis | Yes | Weight loss, anorexia, reduced general condition | 6 months | Perihepatic abscess with Connection to the pleural space | Laparotomy and drainage |
| 17 | Ray S, India (74) | 2021 | 48 | M | NR | NR | Right upper abdominal pain, low-grade fever and swelling on the site of the axillary port | 39 months | Parietal wall abscess | Surgical removal |
| 18 | Mehmood, UK (59) | 2021 | 65 | M | Symptomatic cholelithiasis | Yes | Long standing dry cough, fever and painful swelling over the back in the right paraspinal area | 8 years | Large abscess in the right paraspinal region and retroperitoneal abscess | Incision and drainage |
| 19 | Guruvaiah, USA (36) | 2021 | 61 | M | Acute cholecystitis | Yes | 1-year history of intermittent RUQ pain, recurrent bronchitis and pneumonia with mucopurulent cough and sputum since his LC | Recurrent pneumonia since his LC | Bronchobiliary fistula | Trans-diaphragmatic takedown of the Fistula and right hepatic middle lobe wedge resection |
| 20 | Djelassi, Belgium (27) | 2021 | 82 | M | Perforated necrotic cholecystitis | NR | Chronic fistula at the RUQ | 8 years | Abscess between the right internal oblique and transverses abdominis | Fistulectomy and drainage |
| 21 | Tchercansky, Argentina (79) | 2020 | 69 | M | Gallbladder empyema | Yes | Thoracic pain, cough and fever | 5 months | Loculated pleural effusion of the Right Hemithorax in posterior cost-diaphragmatic recess | CT guided thoracic drainage initially and then Lung decortication by Video Assisted Thoracoscopy |
| 22 | Kafadar, Turkey (45) | 2020 | 42 | F | NR | NR | Painful swelling in suprapubic region persistent for 3 days | 10 years | Omental granuloma | Partial omentectomy |
| 23 | Marçal, Portugal (56) | 2020 | 79 | F | Symptomatic cholelithiasis | NR | Painful right lumbar mass | 3 years | Right subcutaneous lumbar abscess | Surgical drainage |
| 24 | Bolat, Turkey (19) | 2020 | 62 | M | Acute Cholecystitis | NR | 4-year history of swelling of both right and left groins | 5 months | Incidental finding in the right inguinal hernial sac | Surgical excision |
| 25 | Heywood, Australia (40) | 2019 | 70 | M | Emergency LC | NR | Incidental finding in the right inguinal hernial sac | 5 years | Incidental finding in the right inguinal hernial sac | Surgical excision |
| 26 | Cummings, USA (24) | 2019 | 70 | M | Emphysematous cholecystitis and liver abscess | Yes | vague abdominal discomfort | 2 years | Sub hepatic abscess | Surgical exploration + drainage |
| 27 | Akhtar, Pakistan (6) | 2018 | 78 | M | NR | NR | Recurrent bouts of abdominal pain and fever for the previous 2 weeks in the RUQ | 10 years | 19 cm Right subdiaphragmatic and retroperitoneal abscess | CT-guided drainage |
| 28 | Tyagi, USA (81) | 2018 | 70 | F | Acute Cholecystitis | Yes | Septic shock with fevers, chills, lethargy, altered mental status, right hip pain and an inability to move her hip or leg | 2 months | Iliopsoas abscess and periprosthetic hip infection | Surgical drainage |
| 29 | Capolupo, Italy (22) | 2018 | 73 | M | Chronic cholecystitis | Yes | Peritoneal nodule detected during follow up for kidney stones | 16 months | Mimicking peritoneal carcinomatosis | Laparoscopic excision |
| 30 | Urade, Japan (82) | 2018 | 68 | M | Gangrenous Cholecystitis | Yes | Left upper abdominal pain | 7 months | Omental abscess and ascites around the spleen | Laparoscopic partial omentectomy and abscess drainage |
| 31 | Ologun, USA (66) | 2018 | 52 | F | Biliary colic | Yes | Occasional postpranding epigastric pain | 4 years | Calcified intraabdominal mass within the omentum detected in routine follow up for laparoscopic sleeve gastrectomy | Laparoscopic resection of the mass |
| 32 | Stroobants, Belgium (77) | 2018 | 72 | F | Symptomatic cholelithiasis | NR | Intermittent complains about RUQ pain | NR | Subhepatic abscess | Open drainage |
| 33 | Kaplan, Israel (46) | 2018 | 74 | M | NR | NR | Six months vague RUQ pain | 10 years | Perihepatic abscess | Laparoscopic drainage |
| 34 | Kaplan, Israel (46) | 2018 | 41 | F | NR | NR | One-month vague RUQ pain | 3 years | Perihepatic abscess | Laparoscopic drainage |
| 35 | Koichopolos, Canada (51) | 2017 | 80 | M | Biliary disease | NR | Gastric outlet obstruction, 30 pounds weight loss, progressively worsening nausea, vomiting and significant gastroesophageal reflux | 5 years | bulky circumferential irregular thickening and enhancement of the gastric wall at the level of the pylorus | Billroth II distal gastrectomy |
| 36 | Canna, UK (21) | 2017 | 79 | F | Chronic cholecystitis | NR | Painful and firm mass on the right flank | 5 years | Retroperitoneal abscess | Surgical drainage |
| 37 | Lentz, USA (54) | 2017 | 57 | M | Symptomatic cholelithiasis | NR | Cough and right flank pain | 2 years | Perihepatic, pulmonary and renal abscesses | Thoracic drainage |
| 38 | Faour, Syria (30) | 2017 | 44 | F | Symptomatic cholelithiasis | NR | Mass in the RUQ associated with pain, nausea and early satiety for the last 6 months | 6 years | Intra-abdominal cystic mass | Surgical excision |
| 39 | Ragozzino, Italy (72) | 2016 | 63 | M | Chronic cholecystitis | NR | Intermittent vague discomfort of RUQ | 2 years | Subphrenic abscess | Laparotomy, 3 × 3 cm mass excised |
| 40 | Kim, Korea (49) | 2016 | 59 | M | NR | NR | Constant RUQ pain | 5 months | Retroperitoneal abscess | Laparotomy, 5 × 5 cm retroperitoneal mass was excised |
| 41 | Goodman, USA (32) | 2016 | 87 | F | Acute Cholecystitis | NR | Right flank pain and tenderness | 4 years | Right flank soft tissue tumour extending into the abdominal wall | Surgical excision |
| 42 | Moga, Romania (60) | 2016 | 66 | F | Acute Cholecystitis | NR | Fever and large abscess in the right lumbar region | 4 years | Right lumbar region abscess and subhepatic abscess | Laparoscopic drainage |
| 43 | Bedell, USA (16) | 2015 | 41 | F | Symptomatic cholelithiasis | NR | Dysmenorrhea progressed to chronic pelvic pain unrelated to menses | 9 years | Pelvic abscess | Laparoscopic drainage |
| 44 | Binagi, USA (18) | 2015 | 58 | M | Symptomatic cholelithiasis | NR | Continuous but waxed and waned pain, reaching levels eight out of ten of Likert scale | 3 years | Perihepatic abscess | Laparoscopic drainage |
| 45 | Grass, Switzerland (18) | 2015 | 75 | M | Acute cholecystitis | NR | Recurrent subcutaneous abdominal wall abscess with occasional, spontaneous drainage of pus | 3 years | Abdominal wall abscess in the periumbilical port site | Surcical excision and drainage |
| 46 | Noda, Japan (64) | 2014 | 52 | NR | Symptomatic cholelithiasis | NR | Incidental US finding during medical check up | 7 months | Subhepatic abscess | Percutaneous abscess drainage |
| 47 | Noda, Japan (64) | 2014 | 41 | NR | Symptomatic cholelithiasis | NR | RUQ pain | 13 months | A rounded mass in the subhepatic space | Open drainage |
| 48 | Ahmad, UK (5) | 2014 | 37 | F | Symptomatic cholelithiasis, incidental pT1a gallbladder cancer | Yes | Recurrent RUQ pain | 2 years | Multiple tumour embedded gallstones on the diaphragm and lesion in segment VI of the liver | Surgical excision of diaphragmatic nodules and liver segmentectomy VI |
| 49 | Lee, Korea (53) | 2013 | 65 | M | Recurrent acute cholecystitis | Yes | NR | 7 months | Subhepatic abscess | Laparotomy, drainage |
| 50 | Lee, Korea (53) | 2013 | 55 | F | Gangrenous cholecystitis | Yes | NR | 18 months | Cul de sac abscess | Laparotomy, drainage |
| 51 | Lee, Korea (53) | 2013 | 48 | F | Recurrent acute cholecystitis | Yes | NR | 31 months | Umbilical fistula | Prolonged wound care |
| 52 | Lee, Korea (53) | 2013 | 72 | F | Gangrenous cholecystitis | Yes | NR | 4 months | Right flank portal fistula | Prolonged wound care |
| 53 | Lee, Korea (53) | 2013 | 80 | M | Recurrent acute cholecystitis | Yes | NR | 2nd post-operative day | Peritonitis | Antibiotic administration |
| 54 | Morris, USA (62) | 2013 | 71 | F | NR | NR | Pulmonary complains, diffuse abdominal pain, associated with nausea and emesis lasted for 24 h | 15 years | Ileocolic torsion and cecal volvulus | Laparotomy, ileocecectomy |
| 55 | Peravali, UK (70) | 2013 | 61 | M | Acute cholecystitis | Yes | 12-month history of persistent RUQ pain, 8 KG weight loss, anorexia, night sweats, intermittent pyrexical episodes | 3 years | Sub hepatic abscess | Laparoscopic drainage |
| 56 | Peravali, UK (70) | 2013 | 86 | M | Acute cholecystitis | Yes | Chronically discharged right back fistula | 5 years | Subphrenic abscess with atmospheric fistula | Lap drainage |
| 57 | Dobradin, USA (28) | 2013 | 82 | M | Elective cholecystectomy | NR | RUQ pain lasting for 2 months | 8 years | Right flank abscess | Incision and drainage |
| 58 | Chatzimavroudis, Greece (23) | 2012 | 72 | F | Symptomatic cholelithiasis | Yes | High fever, chills and constant pain in the Right lumbar region for 2 days | 6 months | Retroperitoneal abscess | CT-guided drainage |
| 59 | Gorospe, Spain (34) | 2013 | 63 | M | Acute cholecystitis | NR | Fever, malaise, weight loss | 6 weeks | Fever of unknown aetiology | NR |
| 60 | Anrique, Chile (10) | 2013 | 60 | NR | NR | NR | Incidental finding during Lap Gynaecologic procedure | 14 years | Multiple gallstones incrusted in the Douglas’ pouch | Surgical removal |
| 61 | Arai, Japan (11) | 2012 | 65 | M | Symptomatic cholelithiasis | NR | Abnormal liver mass detected on ultrasonography during a periodic medical check-up | 4 years | Subphrenic abscess | Partial resection of the liver and right diaphragm |
| 62 | Papadopoulos, Greece (68) | 2012 | 86 | F | NR | NR | Incidental finding during right hemicolectomy | 8 years | Gallstones embedded in the omentum | Laparotomy, Removal during right hemicolectomy |
| 63 | Singh, USA (75) | 2012 | 42 | F | NR | NR | Worsening right-sided tenderness and pain, low grade fever, night chills, weight loss | 7 years | Subhepatic retroperitoneal inflammatory abscess | Laparotomy, Surgical excision of 4 × 6 cm |
| 64 | Rammohan, India (73) | 2012 | 50 | M | Calculous cholecystitis | NR | Minimally painful, slow progressing mass in the RUQ for the last two years | 4 years | 10 × 5 cm organised extrahepatic mass in the sub-diaphragmatic space extending onto the soft tissues of parietal wall | Laparoscopic piecemeal excision |
| 65 | Kayashima, Japan (47) | 2011 | 57 | F | Acute cholecystitis | Yes | Incidental abdominal US showed 3 liver lesions | 3 years | Inflammatory pseudotumour of the liver | Posterior segmentectomy and concomitant resection of the diaphragm |
| 66 | Hussain, Saudi Arabia (43) | 2010 | 33 | NR | Acute cholecystitis | Yes | Intermittent attacks of RUQ pain, nausea, vomiting for 7 months | 9 years | Discharging abdominal wall abscess extending to the retroperitoneum | Incision and drainage |
| 67 | Pottakkat, India (71) | 2010 | NR | F | Symptomatic cholelithiasis | NR | Fever, malaise, tender right subcostal swelling | 11 years | Dumbbell abscess in the perihepatic area | Open drainage |
| 68 | Bouasker, Tunesia (20) | 2010 | 57 | F | Acute cholecystitis | NR | Inflammatory painful swelling of the right renal fossa | 8 years | Subcutaneous collection and cutaneous fistula | Excision + Drainage, laparoscopic excision of the fistulous tract |
| 69 | Gooneratne, New Zealand (33) | 2010 | 54 | NR | Acute cholecystitis | NR | Recurrent urinary tract infections | 14 years | Colovesical fistula | Surgical repair of the fistula |
| 70 | Helme, UK (39) | 2009 | 77 | F | NR | NR | Night sweets, right back pain and loin swelling for 2 weeks | 5 years | Complex subphrenic, subhepatic and subcutaneous abscesses | US-guided drainage. Patient declined operation to remove the offending gallstones |
| 71 | Morishita, Japan (61) | 2009 | 67 | NR | Symptomatic cholelithiasis | NR | Incidental finding during FU for aneurysm | 1 year | Granuloma mimicked malignancy | Conservative treatment |
| 72 | Dasari, UK (25) | 2009 | 67 | F | Acute cholecystitis | NR | Recurrent lower abdominal pain | 2 years | Nodules mimicking peritoneal metastases | Laparoscopic excision |
| 73 | Maempel, UK (55) | 2009 | 42 | F | Symptomatic cholelithiasis | NR | Suspicious of strangulated recurrent paraumbilical hernia | 10 years | Abdominal wall abscess | Incision and Drainage |
| 74 | Hougård, Denmark (42) | 2008 | 64 | F | Acute cholecystitis | Yes | Fistulas on the abdomen | 7 years | Atmospheric fistula | Surgical excision |
| 75 | Arishi, Saudi Arabia (12) | 2008 | 45 | F | Symptomatic cholelithiasis | NR | Central colicky abdominal pains and swelling lasted for 6 months | 15 years | Cystic mass of the rectus abdominis | Surgical excision |
| 76 | De Hingh, Netherlands (26) | 2007 | 41 | W | Acute cholecystitis | Yes | Abdominal pain and purulent vaginal discharge | 1 year | Rectovaginal pouch abscess | Surgical excision |
| 77 | Stupak, USA (78) | 2007 | 72 | F | NR | Yes | Fever, nausea, anorexia, and pain in the RUQ lasting for 3 weeks | 11 years | Subhepatic collection | Percutaneous drainage |
| 78 | Pantanowitz, USA (67) | 2007 | 53 | F | Symptomatic cholelithiasis | NR | Pelvic pain | 7 years | Left ovar granuloma | Surgical excision |
| 79 | Wehbe, Australia (87) | 2007 | 80 | NR | Symptomatic cholelithiasis | NR | Abdominal pain, nausea, diarrhoea | 10 years | Mass in the right lower quadrant | Laparoscopic excision |
| 80 | Wittich, USA (89) | 2007 | 42 | F | Symptomatic cholelithiasis | NR | Severe metrorrhagia, dysmenorrhea | 13 months | Abscess in the pouch of Douglas | 16 gallstones discovered after transvaginal hysterectomy |
| 81 | Bhati, UK (17) | 2006 | 52 | F | Symptomatic cholelithiasis | NR | Upper abdominal pain | 1w | Liver abscess | Open drainage |
| 82 | Bhati, UK (17) | 2006 | 60 | F | Symptomatic cholelithiasis | NR | Fever and pain in her back | 28 months | Subhepatic abscess | Open drainage |
| 83 | Bhati, UK (17) | 2006 | 56 | NR | Symptomatic cholelithiasis | NR | Fever and pain of the upper abdomen | 7 years | Subdiaphragmatic abscess | Incision and Drainage |
| 84 | Ianniti, USA (44) | 2006 | 70 | M | NR | NR | Generalised aches and pains | 3.5 years | Subphrenic and pleural abscess | Open and US guided drainage, due to recurrence open removal |
| 85 | Hand, USA (44) | 2006 | 50 | F | Biliary pancreatitis | NR | Pain, fever, large fluctuant mass lateral to umbilicus | 2 years | Abdominal wall abscess | US-guided drainage, later local exploration and excision of the abscess |
| 86 | Viera, Italy (84) | 2006 | 72 | NR | Symptomatic cholelithiasis | NR | Fever, general malaise and weight loss | 18 months | 3 inflammatory lesions in Segment II and VII of the liver | Open excision |
| 87 | Viera, Italy (84) | 2006 | 70 | NR | Acute cholecystitis | Yes | Patient asymptomatic, incidental US finding | 2 months | Hyperechoic images with posterior shadowing were observed in the Morison pouch | Watch and see approach |
| 88 | AlSamkari, USA (84) | 2004 | 36 | NR | Symptomatic cholelithiasis | Yes | Diffuse abdominal pain, nausea, vomiting and weakness | 11 years | Necrotic transverse colon from mid-ascending to just distal the splenic flexure | Surgical excision |
| 89 | Koç, Turkey (50) | 2004 | 75 | M | Symptomatic cholelithiasis | NR | NR | 6 years | Retroperitoneal abscess | Percutaneous drainage |
| 90 | Stevens, USA (76) | 2003 | 68 | F | Biliary pancreatitis | NR | Severe pruritus, nausea, painless jaundice, 30-pound weight loss and acholic stools | 1 year | Subhepatic abscess | Open drainage |
| 91 | Aspelund, Iceland (76) | 2003 | NR | NR | Acute cholecystitis | NR | Symptomatic groin hernia | 10 days | Gallstones in the hernial sac | Removal during hernia repair |
| 92 | Papasavas, Greece (69) | 2002 | 77 | F | Symptomatic cholelithiasis | Yes | Fever, pain | 15 months | Right flank abscess | Surgical removal |
| 93 | Yadav, India (90) | 2002 | NR | NR | Symptomatic cholelithiasis | NR | NR | 1 year | Subphrenic abscess | Open drainage |
| 94 | Van Mierlo, Netherlands (83) | 2002 | 48 | NR | Symptomatic cholelithiasis | Yes | Pain in the RUQ, nausea, vomiting | 2 years | Subhepatic abscess | Open drainage |
| 95 | Hawasli, USA (38) | 2002 | 75 | F | Symptomatic cholelithiasis | NR | Pain, fever | 4 years | Abdominal wall abscess | Open drainage |
| 96 | Hawasli, USA (38) | 2002 | 43 | M | Acute gangrenous cholecystitis | NR | Pain, fever | 2 years | Subdiaphragmatic and subhepatic abscesses | NR |
| 97 | Famulari, Italy (29) | 2002 | NR | NR | Symptomatic cholelithiasis | NR | Dysuria, pollakiuria, vesical tenesmus | 2 years | Urinary bladder granuloma | Partial cystectomy |
| 98 | Werber, USA (88) | 2001 | 64 | F | Symptomatic cholelithiasis | Yes | Low-grade fever with chills, night sweats, weight loss, fatigue | 1 month | Sub hepatic abscess and 3 cm round mass with speculated borders in the right lower lobe of the lung | Right thoracotomy |
| 99 | Yao, China (88) | 2001 | NR | NR | Symptomatic cholelithiasis | NR | NR | 2 years | Periumbilical abscess | Surgical excision |
| 100 | Battaglia, Italy (14) | 2001 | 39 | F | Symptomatic cholelithiasis | NR | Fever and pain | 9 years | Abdominal wall abscess | Surgical excision |
| 101 | Ok E, Turkey (65) | 2000 | NR | NR | Symptomatic cholelithiasis | NR | NR | 3 months | Incisional umbilical port site hernia | Surgical excision |
| 102 | Bebawi, USA (65) | 2000 | 56 | M | Chronic cholecystitis | Yes | Painful swelling of the right groin that was reducible before, and reducible swelling of the left groin | 2 months | Gallstones in the hernial sac | Removed during hernia repair |
| TOTAL | Median 62 (29–87) | 37 M, 47 F, 18 NR | 33 acute cases, 20 NR | 31 yes, 71 NR | Most prevalent: Pain 58, Fever 23, Swelling 18, Nausea/vomiting 11, weight loss 11, none 12 | Median 36 months (1–180) | Total abscesses 60, intraabdominal abscesses 42, retroperitoneal abscesses 8, abdominal wall abscesses 11, lung abscesses 7, mimicking malignancy 8 | Open procedure 68, laparoscopic procedure 18, ultrasound or CT drainage 13, watch and see approaches 2 |
Study characteristics of all articles included.
M, male; F, female; RUQ, right upper quadrant; NR, nonreported; LC, laparoscopic cholecystectomy; KG, kilogram.
We aimed to conduct a census of all cases with complications from lost gallstones after laparoscopic cholecystectomy from 2000 to 2022 reported in the literature. The results should clarify that late complications from spilled gallstones are rare (0.08% to 0.3% of patients) but can cause severe problems that occur at a median of 36 months after the initial operation. However, it should be taken into consideration, that the published literature mainly covers incidental findings and small case series.
Of note, only 32% of reported cases initially had acute cholecystitis, while in the majority of cases, primary LC had been reported as elective procedure for symptomatic gallstone disease. Concerning a concept of a culture of safe cholecystectomy, surgeons should be facile with the following aspects: Knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; correct gallbladder retraction; safe use of energy devices; knowledge of the critical view of safety (including its documentation); awareness of various bailout procedures (e.g., cholecystectomy by the fundus-first approach) in difficult gallbladder cases; use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) at uncertain anatomy; respecting the concept of time-out and thorough documentation (93).
It is also alarming that iatrogenic peroration of the gallbladder was only described in 30% of cases causing postoperative complications, suggesting a much higher number of actual gallbladder perforations during LC. Literature on incidental gallstone spillage may be biased by distinct underreporting, considering that only a minority of surgeons document gallbladder perforation and gallstone spillage. Mullerat et al. reported that only half of the surgeons informed their patients and less than 30% informed the general practitioner if gallstones were lost during surgery. The supposed low importance of these complications is underlined by the fact that only a quarter of the surgeons mention this complication in the surgical explanation (4). Operative difficulty is classified according to Nassar Grade and was found to be a significant independent predictor of 30-day complications and 30-day reinterventions. The score could be used to unify the severity of the disease and the technical difficulty of the operation and can be implemented as a tool to document operative findings. Therefore, it can be used in future research to compare outcome and intraoperative difficulties (94).
Since almost 60% of all complications are abscesses, predominant symptoms are fever, pain, abdominal swelling, weight loss, nausea or vomiting. This should lead to radiological cross-sectional imaging in acute diagnostics, which should quickly lead to the correct diagnosis.
The formation of an abscess can be life-threatening. The percutaneous placement of a drain or catheter under imaging control is an increasingly used medical procedure. It is an effective and safe alternative to surgery, reducing discomfort and hospitalization. An amazing 66.6% of the cases required an open procedure and only 12.7% of the patients could be treated with percutaneous drainage (95). Apparently retained gallstones are a problem for percutaneous techniques, because the removal of stones is complex or even impossible. Variations in the location of retained stones, clinical symptoms and individual risk factors of patients demand a personal treatment strategy. However, minimal invasive techniques should be applied, whenever appropriate. Thus, it remains questionable whether a standardized procedure can be found for this complication. In particular, confusion with peritoneal masses can have severe consequences. Complex symptoms such as gastrointestinal reflux, urinary tract infections or breathing problems may lead to a diagnostic dilemma.
4 Limitations
A collection of case reports has several limitations. As Gavriilidis et al. described, institutional, national, underpowered sample size, learning curve, performance and follow-up bias may have influenced the results. In addition, case reports with a poor outcome, unusual history of the disease and rare complications are more commonly reported in the literature, than those with an uncomplicated course (96).
One way to prevent these biases could be the implementation of international databases that record all complications of laparoscopic cholecystectomy postoperatively and in the follow-up. Therefore, awareness of this complication must be created. Futhermore, there is still a lack of a standardized procedure at the international level for laparoscopic operations for gallbladder diseases. Therefore, the Global Evaluation of Cholecystectomy Knowledge and Outcomes (GECKO) study (GlobalSurg 4) will be an international collaborative initiative that will allow contemporaneous data collection on the quality of cholecystectomies. GECKO is a prospective, international, multicentre cohort study observing patients undergoing cholecystectomy, between 31st July 2023 to 19th November 2023, with follow-up at 30-day and one-year postoperatively. The aim of this study is to define the global variation in compliance to pre-, intra-, and post-operative audit standards including: Interventional radiology service; risk stratification via Tokyo Guidelines 18; timing of surgery; achieving a critical view of safety; intraoperative imaging; initiating different bailout procedures; antibiotic use; use of drains; bile duct injury; 30-day readmission; and critical care (97).
5 Conclusion
This case report and review of the literature shall emphasize the alertness on exact reporting of complications to patients and attending doctors by exact documentation in operating reports, to think of that late complication after LC when the symptoms described above are present, and is simply intended to create general awareness, since many surgeons are probably not aware of the problem. Radiologists may suspect unclear radiopaque concretions in the CT scan as lost gallstones after LC in order to identify the abscess genesis earlier. It should be avoided that lost stones will not be considered in patients with above presented symptoms, as there is not a single note in the operation report about them being spilled.
Surgical management in order to completely evacuate the abscess and remove all spilled gallstones should be the attempted. Generally, laparoscopic approaches must be preferred for accessible abscess collection. However, percutaneous drainage could be considered as bridge to surgery or for patients unfit for surgery. Nevertheless, attempting to treat intra-abdominal abscesses containing spilled gallstones with percutaneous drainage will always bear the risk of incomplete treatment by leaving stones in the abdomen. If gallstones spill intraoperatively during laparoscopic cholecystectomy, all stones should be recovered and copious peritoneal lavage should be performed. The initial administration of antibiotics seems to be of secondary importance, as it seems most important to eliminate the mechanical trigger.
To sum up, most lost gallstones remain clinically silent, but they may cause complications that can become symptomatic after years from surgery. In patients with unexplained abdominal abscess or fistula with a history of cholecystectomy within the last 10 years, lost gallstones should always be considered.
Statements
Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.
Author contributions
LD: Writing – original draft, Writing – review & editing, Formal Analysis, Investigation, Methodology, Project administration. AF: Investigation, Formal Analysis, Writing – review & editing. LH: Data curation, Writing – review & editing. TK: Methodology, Writing – review & editing. PP: Data curation, Writing – review & editing. AP: Data curation, Writing – review & editing. DR: Investigation, Formal Analysis, Writing – review & editing. ST: Project administration, Software, Writing – review & editing. MW: Visualization, Writing – review & editing. RF: Supervision, Writing – review & editing. MB: Resources, Supervision, Validation, Writing – review & editing. PK: Supervision, Writing – original draft, Writing – review & editing.
Funding
The author(s) declare that no financial support was received for the research or authorship of this article.
The author(s) further declare that financial support was received for the publication of this article. This work was supported by Johannes Kepler University Open Access Publishing Fund.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
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Summary
Keywords
spilled, lost, gallstones, laparoscopic cholecystectomy, abscess, case report, systematic review
Citation
Danhel L, Fritz A, Havranek L, Kratzer T, Punkenhofer P, Punzengruber A, Rezaie D, Tatalovic S, Wurm M, Függer R, Biebl M and Kirchweger P (2024) Lost gallstones during laparoscopic cholecystectomy as a common but underestimated complication—case report and review of the literature. Front. Surg. 11:1375502. doi: 10.3389/fsurg.2024.1375502
Received
23 January 2024
Accepted
18 March 2024
Published
09 April 2024
Volume
11 - 2024
Edited by
Antonia Rizzuto, University of Magna Graecia, Italy
Reviewed by
Abdul Wahed Nasir Meshikhes, Alzahra General Hospital, Saudi Arabia
Rahul Gupta, Synergy Institute of Medical Sciences, India
Updates
Copyright
© 2024 Danhel, Fritz, Havranek, Kratzer, Punkenhofer, Punzengruber, Rezaie, Tatalovic, Wurm, Függer, Biebl and Kirchweger.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: P. Kirchweger patrick.kirchweger@ordensklinikum.at
Disclaimer
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