Page 53 - Journal of World Association of Laparoscopic Surgeons

CASE REPORT
Minimal Invasive Management of Gallbladder Perforation

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Jalbaji P More , Shirish R Bhagvat , Prachiti Gokhe , Amol Wagh , Ajay H Bhandarwar 5
AbstrAct
Background: Gallbladder perforation (GBP) is a rare clinical entity but life-threatening complication of cholecystitis with or without stones and
associated with increased rate of mortality and morbidity due to late diagnosis.
Case description: We describe the case of a 51-year-old male patient who presented with abdominal pain and a Niemeier type II GBP. CT scan
revealed a GBP with subhepatic collection and surrounding inflammatory changes. It was communicating through a thin hypodense band
with the cystic duct, distal to an impacted stone. Through laparoscopy, the collection was confirmed to be a subhepatic secondary to GBP. The
cholecystectomy and the abscess cavity treatment were completely handled via laparoscopic approach.
Discussion and conclusion: The case report demonstrates that laparoscopic approach can be a safe and feasible method in order to treat both the
cause and the complication in this situation. Early diagnosis and appropriate minimally invasive approach are the key to manage this condition.
Keywords: Gallbladder perforation, Laparoscopic cholecystectomy, Niemeier classification.
World Journal of Laparoscopic Surgery (2019): 10.5005/jp-journals-10033-1364

IntroductIon 1–4 Department of General Surgery, Grant Government Medical College
In retrospective studies, acute cholecystitis may result in 2–12% and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
of gallbladder perforation (GBP). The most important risk factor is 5 Department of General, Bariatric, GI, HPB, Endocrine MIS, Grant
gallbladder stones. 1 Government Medical College and Sir JJ Group of Hospitals, Mumbai,
According to the inflammation progress and type of perforation, Maharashtra, India
Niemeier is subdivided GBP into three types. 1,5–7 Type I (acute) is Corresponding Author: Jalbaji P More, Department of General
associated with free perforation into the peritoneal cavity. Type II Surgery, Grant Government Medical College and Sir JJ Group of
(subacute) perforation consists in the localization of the fluid at the Hospitals, Mumbai, Maharashtra, India, Phone: +91 9960672080,
perforation site, pericholecystic abscess, and localized peritonitis. e-mail: morejalbaji97@gmail.com
If the perforation site is covered by the omentum, the intestines, or How to cite this article: More JP, Bhagvat SR, Gokhe P, et al. Minimal
the visceral surface of the liver, the infection remains limited in the Invasive Management of Gallbladder Perforation. World J Lap Surg
supra mesocolic space with formation of a plastron, pericholecystic 2019;12(1):45–47.

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fluid, or an intrahepatic abscess. Therefore, the GBP can cause a Source of support: Nil
cholecystohepatic communication with consequent spreading of Conflict of interest: None
the infection into the liver. The type III (chronic) perforation consists
of internal or external fistula formation. 1,3,5
approach is preferred, and while separating the gallbladder

cAse descrIptIon off the gallbladder fossa, the posterior (hepatic) surface of
gallbladder at fundus found to be ruptured. The gallbladder
A 51-year-old male presented to us with complaints of low-grade fever, fossa was irrigated with saline and mopped using a gauze piece.
pain in right hypochondrium since14 days and h/o weight loss. On The frozen calots was meticulously dissected using standard
physical examination, the patient was icteric and Murphy’s sign was laparoscopic instruments (suction cannula) and electrocautery.
positive. His white blood cell count was 15,400/μL and total bilirubin The critical view of safety was achieved. Cystic artery and cystic
was 5.1 mg% with the direct component being 3.4 mg%. Alkaline duct were clipped and divided, and total cholecystectomy was
phosphatase level was 812 IU/L. Ultrasound is ultrasonography performed. Hemostasis was achieved and tube drain was placed
report of abdomen which was suggestive of thickened GB wall with in Morrison’s pouch.
pericholecystic collection gallbladder perforation (GBP). This was The postoperative course was uneventful, the drain was
further investigated with a triphasic CT scan which showed GBP removed on day 2, and patient discharged on day 4. The histo-
over posterior wall with subhepatic collection. Patient was prepared pathology report was chronic eosinophilic cholecystitis with GBP.
for early elective laparoscopic cholecystectomy the following day.
The umbilical port was inserted by Hasson’s method. The dIscussIon
intraoperative findings revealed liver adhesions between inferior
edge of right lobe of liver and omentum. There were omental GBP is a rare complication of acute cholecystitis and cholelithiasis
adhesions to gallbladder with increased vascularity. Around 50 cc and still remains a diagnostic challenge to surgeons. Of all the
pus mixed with bile was there, aspirated, and sent for culture. patients with cholelithiasis, approximately 10% have asymptomatic
After initial adhesiolysis, calots was found to be frozen. Significant cholelithiasis of which 2% may present with a GBP, and mortality
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inflammation was encountered in Calot’s triangle with a short in patients with a perforation is 12–16%. GBP was classified and
and wide cystic duct. So antegrade dissection of gallbladder described by Neimeier in three types (Table 1). 5
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