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 Cholecystectomy:A 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 (24%of 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 (Mirrizzi’s 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