Page 47 - WJOLS - Laparoscopic Journal

Toma Florin

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gallbladder perforation is 13 to 40%, with a mean of 18.3% as an unwanted consequence of a surgical procedure. In
out of those 8 studies with more than 500 LCs. The many institutions, the consequences of spilled stones are
incidence is higher in acute cholecystitis, the most accurate virtually never mentioned as a part of the preoperative
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predictor of rupture being the hydropic gallbladder. On consent process. In case patients are not informed
the other side, the reason for gallbladder perforation is mostly preoperatively about the possibility of bile and gallstone
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correlated with the surgeon’s skill and experience. To spillage, they will be surprised and confused if related
minimize this complication, proper dissection is required. complications appear.
If a perforation occurs, the use of suction devices to Even though spilled gallstones have a low Incidence of
minimize the spilled bile and spilled gallstones as well as the causing complications, they have a large variety of different
use of an endo-bag is mandatory. If possible, the hole in the postoperative problems. In order to remove the lost
gallbladder should be closed by the grasp forceps or by an gallstones for preventment of further complications, every
endoclip or endoloop. The abdominal cavity should be effort should be made, but conversion is not mandatory.
intensively irrigated immediately to reduce the spillage of When abscesses due to spilled gallstones occur, open or
laparoscopic removal should be preferred to interventional
bile and gallstones.
drainage.
Management of Spilled Gallstones
REFERENCES
Careful removal of as many stones as possible should be
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following laparoscopic cholecystectomy: Incidence,
abdominal cavity, either through gallbladder perforation complications, and management. Surg Endosc 2004;18:1200-07.
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during dissection or extirpation of the gallbladder. After 2. Johnston S, O’Malley K, McEntee G, et al. The need to retrieve
collecting the visible stones, in order to minimize the number the dropped stone during laparoscopic cholecystectomy. Am J
Surg 1994;167:608 -10.
of lost gallstones, intense irrigation and suction should be 3. Hornof R, Pernegger C, Wenzl S, et al. Intraperitoneal
performed carefully, without spreading the gallstones into cholelithiasis after laparoscopic cholecystectomy—behavior of
difficult accessible sites. The use of an intra-abdominal bag ‘lost’ concrements and their role in abscess formation. Eur Surg
and a laparoscopic grasper, a 10 mm suction device, may Res 1996;28:179-89.
facilitate the gallstones retrieval. 25 4. Zisman A, Loshkov G, Negri M, et al. The fate of long-standing
intraperitoneal gallstone in the rat. Surg Endosc 1995;9:509 -11.
Most authors do not advise conversion to open surgery. 5. Yerdel MA, Alacayir I, Malkoc U, et al. The fate of
They recommend that in cases of patients with a high intraperitoneally retained gallstones with different morphologic
probability for lost gallstones or acute cholecystitis with and microbiologic characteristics: An experimental study. J
visibly infected bile therapeutic antibiotics should be used Laparoendosc. Adv Surg Tech A 1997;7:87-94.
in cases of spilled gallstones. 6. Agalar F, Sayek I, Agalar C, et al. Factors that may increase
Other studies 1,8 emphasize the importance of morbidity in a model of intra-abdominal contamination caused
by gallstones lost in the peritoneal cavity. Eur J Surg
documentation and patient information. They advise that in 1997;163:909-14.
the medical report the surgeon should alert the clinician in 7. Aytekin FO, Tekin K, Kabay B, et al. Role of a hyaluronic-acid
the future to the possibility of stones causing any subsequent derivative in preventing surgical adhesions and abscesses related
problems that might lead to earlier diagnosis. Moreover, the to dropped bile and gallstones in an experimental model. Am J
Surg 2004;188:288-93.
medicolegal risk for further prolonged diagnosis may be 8. Brockmann JG, Kocher T, Senninger NJ, Schurmann GM.
reduced by informing the patient, in case of late Complications due to gallstones lost during laparoscopic
complications occurrence. However, this might also provoke cholecystectomy. Surg Endosc 2002;16:1226-32.
unnecessary repeated examinations. 9. Welch NT, Hinder RA, Fitzgibbons RJ, Rouse JW. Gallstones
in the peritoneal cavity. Surg Laparosc Endosc 1991;1(4):
CONCLUSION 246-47.
10. Bonar JP, Bowyer MW, Welling DR, Hirsch K. The fate of
In our opinion, each and every surgical procedure has a retained gallstones following laparoscopic cholecystectomy in a
potential of unwanted or unexpected outcome. The main prairie dog model. J Soc Laparoendosc Surg 1998;2:263-68.
purpose for all surgeons is to minimize the physical and 11. Chin PT, Boland S, Percy JP. Gallstone hip and other sequelae
of retained stones. HPB Surg 1997;10:165-68.
psychological discomfort for the patient, and sometimes 12. Zamir G, Lyass S, Pertsemlidis D, Katz B. The fate of the
this implies managing their own complications with minimal dropped gallstones during laparoscopic cholecystectomy. Surg
harm to the patient. Thus, a complication can be accepted Endosc 1999;13:68-70.

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