Page 45 - WJOLS - Laparoscopic Journal

Toma Florin

OPERATIVE TECHNIQUE Other common encountered complication were fistula
formation, which occurs across a broad spectrum, ranging
The laparoscopic procedure has been performed by either from fistulas of the skin or umbilicus to colocutaneous or
an attending surgeon or resident under direct staff colovesical fistulas. Due to the fact that complications of
supervision. The study included both elective and emergency lost gallstones in LC are infrequent, occurring in
cases. A four-trocar technique with a 30° angled approximately 1,7 per 1000 LCs, diagnosis becomes very
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laparoscopic video camera was used. Dissection of the difficult, if the complication occurs late. The incidence of
gallbladder was performed using a combination of lost gallstones in LC may be summarized at approximately
electrocautery and blunt dissection with fine graspers, and 2%, out of 8 studies with more than 500 LCs. From this
the cystic artery and cystic duct were ligated with titanium estimation, we can calculate that 8.5% of these lost gallstones
clips. The gallbladder was removed through either the will lead to a complication.
umbilical or epigastric port. When perforation of the During this systemic search of the literature, several
gallbladder occurred, attempts were made to retrieve all factors that lead to the development of severe septic
spilled stones, and the peritoneal cavity was irrigated with complications were found. As shown in several studies, 2-7
saline solution to evacuate the spilled bile. Patients typically whether the bile is infected or not, bile and gallstones are at
received one preoperative and one postoperative dose of an increased risk for abscess formation and formation of
antibiotic, most commonly a cephalosporin. In patients with adhesions. The type of stones is one of the factors involved
acute cholecystitis, especially when the bile culture was in complication occurence; more experimental studies and
positive, broad-spectrum antibiotics were administered for reported cases show that the bacterial contamination is less
a longer period depending on the clinical situation. in cholesterol calculi than in pigment stones (black, brown
or mixed). The size and number of spilled gallstones is
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RESULTS another involved factor. In Brockmann et al systemic
review, a total of 91 patients had 555 stones in locations
The purpose of the study was to perform a systemic literature ranging from the abdominal wall to all possible intra-
search in order to identify the different possible outcomes abdominal sites. At the time of reoperation, 40% of these
of the infrequent but severe laparoscopic cholecystectomy patients were found to have 15 or more stones. Based on
complications, the different possible outcomes, few these systemic observations, they concluded that the risk
suggestions to prevent these and their management. The factors for complications because of lost gallstones are, as
most frequent complications that were found published are: summarized by Woodfield et al, stone size (>1.5 cm),
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intra-abdominal abscesses and abscesses of the abdominal spillage of pigment stones, acute cholecystitis with infected
wall, followed by subhepatic and subphrenic abscesses. bile, multiple stones (>15 stones), and age. From the
(Fig. 1). published case reports and studies as well as the
experimental studies, we can conclude that spilled stones
are no indication for laparotomy if the following therapeutic
guidelines are followed.

DISCUSSION
A great number of animal experiments have been conducted
in order to study the fate of the retained intraperitoneal
gallstones.
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Using the rat model, Zisman et al , performed a study
during a follow-up period of one year and he found no
systemic deleterious outcome except for minor local effects
due to the presence of the implanted gallstones.
They have concluded that there is no systemic illness
associated with the presence of gallstones in the peritoneal
cavity and the local effects consisted mainly of fibrosis,
Fig. 1: CT scan which shows intra-abdominal mass representing
the gallstones and the surrounding reaction adhesions, and mild local inflammatory reaction in 83% of

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