Spilled Gallstones During Laparoscopic Cholecystectomy

1
Spilled Gallstones During Laparoscopic
Cholecystectomy

• The Journal Club Meeting POWH
• 6 December 2004
• Presenter Alexander Koshman

2
Background

• Gallbladder perforation during LC with spillage
  of bile and gallstones occurs in a substantial
  number of patients
• Most surgeons believe that free intra-peritoneal
  stones are not a justification for conversion to
  laparotomy even if a large number of stones are
  left in situ
• Outcome of unretrieved gallstones in the
  peritoneal cavity after GB perforation during LC

3
Background

• Question raised
• Do spilled gallstones matter?

4
Parameters of Search

• Two Databases Medline, PubMed
• Limit search to 1996 to November week 4 2004
• Keywords Spilled gallstones
• Lost gallstones
• Retained gallstones
• Dropped gallstones

5
Search Results

• Spilled gallstones 36 titles
• Retained gallstones 19 titles
• Lost gallstones 18 titles
• Dropped gallstones 17 titles

6
Search Results

• Case reports 70
• Technical aspects of spilled stones retrieval 8
• Literature review 5.5
• Case report Lit. R/v 5.5
• Animal models 3
• Retrospective studies 3
• Prospective studies 3
• Randomized, placebo-controlled studies not
  available

7
Spilled Gallstones after Laparoscopic
CholecystectomyA Retrosperctive analysis of
10,174 cases

• M.Schafer, C.Suter, Ch.Klaiber, L.Krahenbuhl
• Surgical Endoscopy, Ultrasound and Interventional
  Techniques, Vol.12, No.4, 1998
• Department of Visceral and Transplantation
  Surgery, University of Berne, Switherland

8
Study design

• Objectives to investigate the frequency,
  complications, and management of spilled
  gallstones after laparoscopic cholecystectomy
• Methods 10,174 patients undergoing LC at 82
  surgical institutions (universities, country and
  district hospitals, and surgeons in private
  practise) in Switherland were retrospectively
  analyzed
• The follow-up of all patients was guaranteed by
  contacting either general practitioner or the
  patient

9
Results

• 581 patients (5.7) with intraoperative gallstone
  spillage into the peritoneal cavity
• 547 of these cases were finished
  laparoscopically, in 34 cases operation was
  converted to open procedure during which all the
  spilled gallstones were removed
• Only 8 patients (0.08) had a serious
  postoperative complications due to
  intraabdominally lost gallstones

10
Results

• 7 patients developed intraabdominal abscess
  formation requiring reoperation
• 3 of these 7 pts not only developed I/abd abscess
  but also fistulas and abscess formation into the
  abdominal wall
• In 1 pt who complained of upper abdo pain
  postoperatively, gallstones had become sandwiched
  between the liver and diaphragm and were
  retrieved by open access
• 4 pts were reoperated in the early post/op course
  (2-21 days) 4 pts were reoperated on after 2.3,
  4.5, 5.0 and 18.4 months

11
Conclusions

• Spillage of gallstones during LC is a common
  problem (5.7), but
• Serious postoperative complications are very rare
  (0.08)
• Elderly pts with acute cholecystitis , infected
  bile and spilled stones may have an increased
  risk of intraabdominal abscess formation

12
Conclusions

• Perforation and rupture of GB should be prevented
  whenever possible
• In cases of spilled gallstones, the surgeon must
  try to retrieve lost stones and the abdominal
  cavity should be irrigated to dilute the infected
  bile and wash out spilled stones
• There is no need for obligatory conversion to an
  open procedure for stone retrieval as the
  incidence and mortality rate of serious
  complications are very low

13
The outcome of unretrieved gallstones in the
peritoneal cavity during Laparoscopic
Cholecystectomy A prospective Analysis

• M.A.Memon, R.K.Deeik, T.R.Maffi, R.J.Fitzgibbons
• Surgical Endoscopy, Ultrasound and Interventional
  Techniques, v.13, 1999
• Department of Surgery, Queens Medical Centre,
  Nottingham, UK
• Department of Surgery, Creighton University,
  Omaha, USA

14
Study design

• In 7-year period between 1989 and 1996,
  prospective data were maintained on 856 pts who
  underwent LC by a single surgeon
• 64 of patients were available for prospective
  long-term follow-up through the mail (76) and by
  telephone (24)
• The mean follow-up was 44 months ( range 5 to 92
  months)

15
Results

• Gallbladder perforation occurred in 311 (36) of
  patients
• 165 of 856 pts (16) had documented gallstone
  spillage into the abdominal cavity
• Prospective follow-up identified 4 pts with
  short-term complications and 1 long-term
  complication

16
Results

• Short-term complications
• - Pyrexia for 10 days postoperatively(Abx PO)
• - Cellulitis at a drain site (Abx PO)
• - Umbilical wound abscess drained
  spontaneously
• - Sterile subphrenic collection 1 mo postop
  percutaneous drainage under CT guidance

17
Results

• Long -term complication in 1 patient
• spontaneous erosion of gallstone from the back
  8 months postoperatively
• -Multiple episodes of pyrexia after d/c from the
  hospital
• -Series of diagnostic tests incl U/S, CT, white
  cell scintigraphy - failed to reveal the cause
• -Continuing pyrexia, abdo pain, 8/12 later -
  developed painful mass R back -incis/drain

18
Conclusions

• Every effort should be made to recover all
  spilled stones at the time of laparoscopic
  surgery. No conversion to open procedure
• Large and medium-size stones can be retrieved
  individually by mechanical devices such as
  grasping forceps, Dormia basket, plastic
  retrieval bag
• Multiple small stones - wide-bore
  suction-irrigation device helpful
• Close holes in GB using clips or sutures to
  minimise further spillage of bile and stones

19
Limitations of the Study

• Single institution
• Single surgeon
• Telephone follow-up (24of pts), mail follow-up
  (76)
• 64 of pts were available for prospective
  follow-up (106 out of 165)
• Only patients with documented gallstone spillage
  were followed-up
• Mean follow-up was 44 months (range 5 to 92
  months) - is it long enough?

20
Spilled Gall Stones during Laparoscopic
Cholecystectomy a Review of the Literature

• T.Satesh-Kumar, A.Saklani, R.Vinayagam,
  R.Blackett
• Postgraduate Medical Journal, v.80(940), 2004
• Department os Surgery, University Hospital of
  North Durham, UK

21
Incidence and Presentation

• GB perforation occurs infrequently and is
  reported in the range of 10-40 in various series
• Incidence of stone spillage is even less frequent
  and varies in 6-30 range
• Presentation time interval from 1 month to 20
  years with peak incidence around 4 months
• Infective complications are noted more often in
  elderly pts (poorer immunological response)

22
Incidence and Presentation

• Spillage can occur during dissection of GB off
  the liver bed, tearing with grasping forceps, or
  during extraction of GB through the port
• Incidence more common when operating on an
  acutely inflamed GB, in men, the elderly, obese
  patients, and in presence of adhesions
• Stones spilled may remain adjacent to the liver
  or may migrate to various distant sites
• In majority of cases cause no bother and remain
  benign
• Complications occur in 0.08-0.3 of patients

23
Modes of Clinical Presentation

• Infective
• Local
• Distant
• Cutaneous complications
• Mechanical
• Migration to other systems
• Systemic

24
Infective complications

• Local
• Liver abscess
• Subhepatic abscess
• Retrohepatic abscess
• Intra-abdominal abscess
• Distant
• Retroperitoneal abscess
• Loin abscess
• Pelvic abscess
• Gallstone hip

25
Cutaneous complications

• Sinus formation
• Port site infection
• Granuloma formation
• Colocutaneous fistula

26
Mechanical complications

• Intestinal obstruction
• -Abscess between loops of the bowel
• -Bowel wall erosion and ileus
• Lodgement in distal hernial sacs
• -Femoral canal filled with gallstones
• -Incarcerated indirect inguinal hernia
• -Middle colic artery thrombosis as a result
  of retained intraperitoneal Gstone
• Jaundice due to extrabiliary gallstone pressure
  (Mirrizzis syndrome)

27
Migration to other systems

• Pelvic migration
• Dyspareunia, tenesmus, dysmenorrhea, pelvic
  pain, ovarian cholelithiasis
• Chest
• Empyema, cholelithoptysis(gallstone
  expectoration), complex pleural effusion, massive
  haemoptysis from a lung abscess
• Urinary tract
• Haematuria, vesical granuloma, stone excretion

28
Systemic presentation

• Septicaemia
• Recurrent Staphylococcal bacteremia

29
Predisposing Factors

• Animal models
• Combination of multiple stones and infected bile
  implanted in the peritoneal cavity increases
  adhesions and intraabdominal abscesses occurrence
• Chemical composition of stones has a significant
  influence
• Infective complications are more likely to occur
  with bilirubinate stones because they often
  contain viable bacteria

30
Conclusion

• Complications from spillage of gall stones during
  LC are extremely rare
• Can present months or years after the
  cholecystectomy with septic complications not
  necessarily located in the RUQ
• Surgeon should take utmost care to prevent
  spillage and attempt to remove all visible stones
  at the time of surgery

31
Conclusion

• If spillage occurred it should be recorded
  clearly in the operative notes
• There is no indication for routine conversion to
  open surgery
• Patients should be informed to minimise any legal
  implications, and to aid in the early diagnosis
  of later complications