Laparoscopic Completion Cholecystectomy for Recurrent Symptomatic Cholelithiasis. Case Report and Review of the Literature

Luis R Benavente-Chenals, MD, Brian J Dunkin, MD, Joanne M Chung, MD, Vadim Sherman, MD, Wega Koss, MD, Patrick R Reardon, MD. The Methodist Hospital Department of Surgery Methodist Institute for Technology, Innovation, and Education Houston, Texas 77030

Background
Laparoscopic cholecystectomy is the standard of care for acute cholecystitis and biliary colic. When Calot’s triangle is severely inflamed, identification of the cystic duct and artery can be challenging increasing the risk of injury to adjacent structures. In this situation, partial cholecystectomy avoids dissection of the triangle and may be the safe alternative. Incomplete cholecystectomy may occur by design or unintentionally. The incidence of partial cholecystectomy is unknown but some authors believe is increasing. Complications of this procedure include recurrent pain due to retained stones or regeneration of stones in the remnant gallbladder. We present a case of cholecystitis in the retained gallbladder caused by newly formed stones and its treatment laparoscopically.

Methods
A 59 year old white woman was referred for surgical evaluation of right upper quadrant pain and tenderness. The pain was located in the epigastrium and right upper quadrant, associated with nausea and vomiting, had no radiation, and was colicky in nature. Her past surgical history was significant for an open cholecystectomy in 1998 for acute cholecystitis. The operative report for this procedure was not obtainable.

Radiologic workup included a CT scan of the abdomen, which revealed an 8 mm fluid collection in the gallbladder bed containing a 3mm hyperdense mass consistent with an incomplete cholecystectomy and a stone in the remnant gallbladder. MRCP showed similar findings.

Results
She was taken to the operating room for laparoscopic removal of remnant gallbladder. The operation identified a remnant gallbladder with a stone which had formed where the gallbladder remnant had been oversewn with a prolene suture. The stone was attached to the suture. The operation was without complication and the patient was discharged to home on the day of her surgery. She remains well and asymptomatic, to this date.

Conclusions
Cholecystectomy may intentionally or unintentionally be incomplete. The use of permanent sutures in contact with the lumen of the biliary tree may serve as a nidus for new stone formation. Both of these complications can successfully and safely be treated by reoperative laparoscopic choecystectomy.


Session: Poster
Program Number: P408
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