Almost 22 years have elapsed since the introduction of LC in 1987. With the evolution of the laparoscopic approach, injury to the biliary tree is recognised as the most serious complication and as such has received most attention by the surgical and legal fraternity.9
Other idiosyncratic complications have come to light and the effects of gallbladder perforation with stone spillage is one which is recognised as producing sporadic but significant morbidity. A literature review revealed only 14 case reports described this rare complication of spilled gallstones leading to abdominal wall abscesses.1–8
This case report describes the recurrence of an abdominal wall abscess due to gallstones spilled in the abdominal cavity 5 years previously at the time of an elective LC. The cause of the abscess was not apparent upon investigation at the index presentation 1 year previously, highlighting the difficulty in diagnosis of this clinical entity. Again on this admission the CT scan showed the magnitude of this large abscess but did not elude to the aetiology. This was only apparent upon surgical drainage of the abscess. One might speculate that had a radiological approach been adopted again the precipitating aetiology might not have come to light. The incidence of bacterobilia in the presence of gallstones is in the order of 30%.9
Prophylactic antibiotics are routinely employed at the time of LC although the benefit that this bestows is hard to quantify as this prophylactic measure is a legacy from the era of open cholecystectomy where its inherent wound risks were frequently problematic.
This complication has an approximate incidence of 0.3% and may occur within 6 months up to 11 years post LC. Abscess formation can be sporadic and variable in its presentation with the capacity for abscess development at remote and diverse sites (intraperitoneal 44.1%, abdominal wall abscess 18.1%, thoracic abscess 11.8%, retroperitoneal abscess, 10.2%). Other stones with concomitant abscess formation have been described at trocar sites and/or within incisional hernias.10
Zehetner et al
conducted a systematic literature review between January 1987 and January 2005 to conclude that although spilled gallstones may have a low incidence of complications, these complications can present in a large variety of problems later on. Without any need to open conversion, the study suggested laparoscopic techniques to remove spilled stones intraoperatively, highlighted the importance of documentation in the operation notes, as well as the role of interventional drainage postoperatively and in late complications.11
This case report highlights the significance of spilled gallstones during LC. It demonstrates the importance of having contingency plans for such an eventuality intraoperatively and the importance of being aware of this complications and the time frame for its development. By way of reflective practice it is important to take steps to minimise this complication and to record its occurrence accurately at the time of surgery, so that those following on might have the best opportunity to recognise and treat this complication expediently.
- Attempts should be made to avoid gallbladder perforation and remove spilled gallstones; thereby complications could be minimised or prevented.
- Spilled gallstones should be documented in the operative notes.
- CT scanning has a low sensitivity for demonstrating gallstones and may be of limited value in diagnosing complications secondary to spilled stones.
- There should be improved training for laparoscopic cholecystectomy and for adopting a safe strategy for gallbladder removal (retrieval bags) and peritoneal salvage of spilled stones should this occur (pelican forceps).
- Although this is a rare complication, laparoscopic cholecystectomy is a common operation and gallstone spillage is also common. The morbidity from spilled stones is difficult to quantify; however, case reports are common and morbidity significant.
- This report highlights the importance of trying to avoid this eventuality and trying to remedy the situation should it occur. One must accurately record this eventuality in the notes for future reference as complications may be delayed.