Page 46 - WJOLS - Laparoscopic Journal

Management of Spilled Stones during Laparoscopic Cholecystectomy

the rats. Seventeen percent of them have not reacted to the without Escherichia coli, sterile bile, or both increased the
presence of the stone at all. These results are in concordance rate of formation of both abscesses and adhesions. In the
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with and also complement Welch et al observation, which same way, Aytekin et al sustains that spilled gallstones and
showed very little, mild inflammatory reaction, no evidence bile cause postoperative adhesions, no matter if the bile is
of infection, and satisfactory clinical outcome in both rabbits infected or not.
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retaining gallstones for up to 3 months, and in humans with Soper and Dunnegan and Schafer et al have analyzed
intraperitoneal gallstones. 9 10,174 laparoscopic cholecystectomies performed at 82
Based on the rat model the authors have concluded that surgical institutions over a 3-year period. They have
a conversion of the laparoscopic procedure to an open discovered that the mortality rate and the incidence of serious
laparotomy has no justification only for the purpose of complications of retained gallstones are extremely low, thus
retrieving a lost stone, however, reasonable effort should have advised surgeons against converting laparoscopic
be made in order to retrieve an escaped gallstone. cholecystectomy to an open procedure.
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Other authors, like Bonar et al reported increased The same opinion is shared by Rice and Associates, at
adhesions and inflammatory response due to retained intra- the Mayo Clinic, who have studied the long-term
abdominal gallstones, especially when these are associated consequences of intraoperative bile and gallstones spillage
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with infected bile. Chin et al also found numerous adhesion during laparoscopic cholecystectomy. They advised
in the rat and inflammatory reactions in dogs with no conversion to an open procedure only in patients for whom
spontaneous resolution tendency, due to lost gallstones. it is not possible to retrieve the majority of the gallstones
2
Johnston et al studied the effects of retained human bile laparoscopically, especially when bacteriobilia is suspected
and gallstones in rats. They found that the combination of or confirmed by Gram stain of the bile. Also they emphasized
gallstones and bile (infected or sterile) in the intraperitoneal the need for removal of as many calculi as possible during
cavity was associated with significant adhesion formation. the laparoscopic procedure. Moreover, they showed that if
the inciting gallstones were not removed, the percutaneous
A few studies have specifically examined the potential drainage of intra-abdominal abscesses was ineffective in
early and long-term consequences of bile spillage and most of their patients. 18
unretrieved gallstones in the abdomen, however, in humans, Hussain reported that of seven patients who harbored
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the natural history of retained gallstones is not documented. dropped surgical clips or spilled gallstones, five had no
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Some reports, like Brueggemeyer et al, demonstrated that complications; in the other two patients, subphrenic
spillage of gallstones can cause intraperitoneal abscess. abscesses, empyemas, and a lung abscess can develop. He
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Zamir et al reported similar findings. Antibiotic prophylaxis suggests that stones may remain silent a long-time in the
may decrease the rate of early complications, especially peritoneal cavity but dropped gallstones and clips represent
infections, although the late sequelae of retained stones are a risk factor for abdominal sepsis. Consequently, during
unaffected. The time between laparoscopy and clinical the laparoscopy, every procedure must be made to avoid
manifestation has been reported to be as long as 9 years. 15 leaving any surgical clips or dropped gallstones in the
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A recent case report by Walch et al has showed that the peritoneal cavity. Laufer et al recommends that if the
spillage of stones during LC occurs in 10% of operations. gallbladder is accidentally perforated, all efforts must be
Late complications associated with this type of surgical taken in order to prevent the spread of the bile and calculi
procedure include abscesses and fistulas in the abdominal and remove the spilled gallstones whenever possible. 20
cavity and on the abdominal wall. Despite the unaffected long-term sequel, any patient
Implanting human gallstones in the peritoneal cavity of with gallbladder perforations and spillage of bile and
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rats, Hornof et al sustain that only cholesterol stones in gallstones should be considered for extension of antibiotic
association with gram-negative bowel germs cause abscess prophylaxis to avoid early complications. Patient records
formations. Other studies sustain that intraperitoneally should be properly kept and checked when necessary.
retained cholesterol gallstones remained inert and are well
tolerated in the abdominal cavity except when they are Management of Gallbladder Perforation
caused by acutely inflamed gallbladder or were crushed The incidence of the gallbladder perforation complications
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(Yerdel et al ). Agalar et al , using a mouse model, showed was analyzed and the management discussed in the recent
1,8
that free gallstones within the peritoneal cavity with or published reviews. During laparoscopy, the incidence of
World Journal of Laparoscopic Surgery, May-August 2010;3(2):103-107 105