Laparoscopic completion cholecystectomy for recurrent symptoms following subtotal cholecystectomy

Thea P Price, MD, Guillaume S Chevrollier, MD, Michael Z Caposole, MD, Michael J Pucci, MD, Francesco P Palazzo, MD, FACS, Ernest L Rosato, MD, FACS, Karen A Chojnacki, MD, FACS. Thomas Jefferson University

Introduction: Subtotal or partial cholecystectomy (PC) has been described as a safe operative option to prevent bile duct injuries in the setting of severe acute and subacute cholecystitis. The long-term sequelae and potential need for reoperation are less known. Herein, we report our experience with laparoscopic completion cholecystectomy.

Methods: A retrospective review of all patients referred to our institution between 2009 and 2014 for completion cholecystectomy was completed. Medical records were reviewed for demographics, details of initial procedure, preoperative workup, and perioperative outcomes.

Results: Five patients met selection criteria (three female and two male patients, ages 25-74). The presenting symptom in all 5 patients was persistent abdominal pain. Two patients had prior open PC, while 3 underwent laparoscopic PC. Mean time from original cholecystectomy was 10 years (range from 1 to 15 years). All 5 patients underwent an extensive preoperative workup including: ultrasound, esophagogastroduodenoscopy, magnetic resonance cholangiopancreatography, computed tomography, endoscopic retrograde cholangiopancreatogram, and Hepatobiliary Iminodiacetic Acid (HIDA) scan. The time to diagnosis after onset of symptoms was approximately 6 months. Preoperative imaging demonstrated a structure indicative of a gallbladder remnant or long stump in all 5 patients. Four patients had cholelithiasis in the remnant gallbladder, none had choledocholithiasis. Gallbladder remnant length ranged from 2.6 cm to 4.2 cm, and a cystic duct stump length of 1.6 cm. All patients had normal liver function tests at the time of operation. In all cases completion cholecystectomies were completed laparoscopically. All patients had post-operative relief of their biliary symptoms.

Conclusion: Retained gallbladder and cystic duct remnants represent possible causes of pain following PC. Those patients presenting with biliary colic symptoms following PC should undergo workup to include review of previous operative reports and complete radiographic evaluation. When other causes of upper abdominal pain are excluded, and imaging findings are supportive of the diagnosis, reoperation should be considered. Laparoscopic completion cholecystectomy should be considered even in the setting of previous open cholecystectomy.