Retained Gallstone after Laparoscopic Cholecystectomy

An 83-year-old female presented to our outpatient clinic with a history of abdominal pain and recurrent sub-hepatic abscesses. At the time of presentation, the patient was maintained on chronic suppressive oral cephalexin. Physical examination was remarkable only for a draining sinus of an epigastric laparoscopic port site that had been opened recently by the operating surgeon for a superficial incisional surgical site infection. One year previously, the patient underwent a laparoscopic cholecystectomy elsewhere that was complicated by an escaped gallstone. The gallstone was visible on a computed tomography (CT) scan of the abdomen (Fig. 1). The calculus measured 1.8 cm diameter and was in the subdiaphragmatic space adjacent to liver segment VII and the insertion of the diaphragm postero-laterally at the level of the ninth intercostal space. An abscess surrounding the gallstone was drained percutaneously on four occasions, yielding the same strain of Escherichia coli each time. At our institution, the gallstone was removed via the bed of a resected right eleventh rib, entering the diaphragmatic sulcus transretroperitoneally above the right kidney. Immediately prior to surgery, an external cutaneous marker was placed under CT guidance to facilitate localization and dissection. No pus or fluid was encountered. Surgical recovery was uneventful.

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FIG. 1.

Axial computed tomography scan of abdomen showing retained 1.8-cm calcified gallstone posterior to the liver, with surrounding phlegmon.

Iatrogenic perforation of the gallbladder during laparoscopic cholecystectomy occurs in approximately 30% of procedures [1], either by tearing of the gallbladder wall during retraction or while the gallbladder is being dissected off the liver bed. Risk factors for spillage of gallstones include male gender, older age, high body mass, and omental adhesions [1]. Although the risk of infection is so low after laparoscopic cholecystectomy that antibiotic prophylaxis is not beneficial [2], spilled gallstones are a documented cause of intra-abdominal abscess and postoperative fever [1,3,4]. Therefore, an effort should be made to retrieve all spilled stones, even though infection therefrom is rare. In a series of 10,174 patients, only 0.08% of patients with spilled gallstones required reoperation for an intra-abdominal abscess [3]; those at risk had advanced age or acute cholecystitis with infected bile and large stones. Given the low incidence of long-term complications with retained gallstones, routine conversion to laparotomy for stone retrieval is unnecessary [3]; whether antibiotic prophylaxis should be instituted or modified as a result of gallstone spillage is unknown. Image-guided percutaneous drainage of an abscess caused by retained gallstones is associated with a high rate of failure; therefore, if gallstones are known to be present, they should be retrieved manually [1]. Often, gallstones are not radiopaque and therefore not visible by CT. Intra-abdominal abscesses form rarely in patients undergoing uncomplicated elective laparoscopic cholecystectomy [4]; therefore, clinicians should have a high degree of suspicion for retained gallstones in a patient who presents with a peri-hepatic abscess after laparoscopic cholecystectomy.

Nather and Ochsner in 1923 were the first to describe the posterior approach via twelfth rib resection for the drainage of subphrenic abscess [5]. Until the advent of percutaneous drainage techniques in the 1980s, this remained an important approach to the right subphrenic space, as contamination of the peritoneal and pleural spaces can be avoided. More recently, Spain et al. showed that a posterior approach via twelfth rib resection for drainage of an infected fluid collection is associated with low morbidity (11%) [6]. Patients who have had numerous abdominal procedures or failed percutaneous drainage are candidates for such an approach.