Amlish Gondal, MD, Vinod Gollapalli, MD, Abdul Khan, MD, Nabajit Chaudhury, MD, Iman Ghaderi, MD, Mac. University of Arizona
We present a case of minimally invasive management of gallstone ileus. The patient is a 50 year old man presented with 3 day history of Epigastric and LLQ abdominal pain and bilious vomiting. He described the pain as intermittent and crampy. His Past medical history was significant for hypertension. He had no history of abdominal surgeries. He was a smoker, drank a six pack of beer per day, and used marijuana.
On physical exam, he was afebrile, hypertensive and tachycardic. He appeared nontoxic. On abdominal exam, he was obese, soft, tender to palpation in epigastric region as well as LLQ. Laboratory values showed elevated white count, elevated BUN and creatinine with evidence of acute kidney injury, and mildly elevated total bilirubin. A CT scan showed a 4 cm calcified stone in the small bowel resulting in mechanical small bowl obstruction. Pnuemobilia was also noted.
The patient was taken to the operating room for laparoscopic abdominal exploration, enterotomy, and extraction of the gallstone. We did not plan to remove the gallbladder at this time. After abdomen was entered and pneumoperitoneum was established, the abdomen was surveyed. The distal small bowel appeared to be collapsed. We ran the bowel proximally from the cecum. We identified a change in the caliber of the small bowel at the proximal ileum where the gallstone laid. We were unable to milk the stone proximally, so we decided to create the enterotomy on the antimesenteric side where the stone was palpated. We opened the small bowel in longitudinal fashion. The gallstone was removed and placed in the endocatch bag for later retrieval.
Using a 3-0 absorbable V-lock, the enterotomy was approximated in a running transverse fashion. We placed multiple Lambert stitches with 3-0 Vicryl as a second layer. Then we examined the bowel and found no evidence of narrowing at closure site. We irrigated and performed a leak test; no leak was seen. The 12 mm port site was dilated and the gallstone was extracted. The right upper quadrant was examined and dense adhesions were noted between omentum, liver, and gallbladder. No other stones were discovered during the exploration.
The patient did well post operatively with return of bowel function on POD2. He was seen in clinic after two weeks and was doing well. Pathology report noted a solid cholesterol stone.
Laparoscopic approach for management of small bowel obstruction due to gallstone is feasible and safe.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 88134
Program Number: V276
Presentation Session: Friday Video Loop (Non CME)
Presentation Type: VideoLoop