Complications of “dropped” gallstones after laparoscopic cholecystectomy: technical considerations and imaging findings

New laparoscopic techniques have revolutionized the practice of surgery. Laparoscopic cholecystectomy has become one of the most commonly performed surgeries worldwide. Although shorter hospital stays and patient comfort have offered clear advantages over open cholecystectomy, the technique has resulted in several specific complications, including bile duct injury and gallbladder perforation. Although rarely clinically significant, intraperitoneal gallstone spillage can cause abscess formation and adhesions. Although these patients can present with a confusing clinical picture, their characteristic radiologic features should be recognized. We present two cases of complicated intraperitoneal gallstone spillage radiologically diagnosed and treated with laparoscopic and interventional radiologic techniques. Received: 13 April 1999/Accepted: 19 May 1999     

LC术后残余胆囊的预防和处理(附11例报告)

目的：探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)后残余胆囊的预防和处理。方法：回顾分析自1998年12月至2003年5月收治的LC术后残余胆囊患者的病历资料。结果：本组11例LC术后残余胆囊均经开腹手术证实,其中6例残余胆囊,3例残余胆囊合并残余胆囊结石,2例胆总管结石行探察术中发现残余胆囊。所有病例均行残余胆囊切除,胆囊标本经病理检查证实均为残余胆囊慢性炎症改变。结论：严格把握LC的适应症和操作规范是防止残余胆囊的关键。     

Recurrent abdominal abscess secondary to a dropped laparoscopic clip: CT imaging

Since being introduced in 1987, laparoscopic cholecystectomy has quickly become the treatment of choice for symptomatic gallstone disease. Computed tomography is an excellent method to evaluate the laparoscopic patient in whom postoperative complication is suspected.     

Single‐incision laparoscopic cholecystectomy for gallbladder torsion: A case report and literature review

We present a case of preoperatively diagnosed gallbladder torsion (GT) that was successfully treated by single‐incision laparoscopic cholecystectomy. An 80‐year‐old woman presented with sudden pain and a palpable mass in the right upper quadrant. Contrast‐enhanced CT revealed ischemic changes, a swollen gallbladder with a V‐shaped distortion of the extrahepatic ducts, and the gallbladder in an abnormal anatomical position; clinical findings indicated GT. We performed single‐incision laparoscopic cholecystectomy and intraoperatively found that the floating gallbladder was twisted counterclockwise by 180° around the cystic duct. After an uneventful postoperative course, the patient was discharged on postoperative day 7. Laparoscopic cholecystectomy for a GT was first performed in 1994, and since then, 28 cases, including ours, have been treated laparoscopically. Laparoscopic cholecystectomy for GT could be the standard treatment for this condition, and single‐incision laparoscopic cholecystectomy may be a good surgical option for patients with GT because of its anatomical characteristics.     

Enlargement of umbilical incision in standard laparoscopic cholecystectomy is frequently necessary: An argument for the single incision approach?

Objective: Cosmetic result after cholecystectomy is up for debate. The aim of this study was to investigate the incidence and extent of enlargement of initial skin and fascia incision in standard laparoscopic cholecystectomy and to detect predictive factors for such an enlargement. Material and methods: The size of the umbilical incision was measured before and after standard laparoscopic gallbladder removal in 391 patients from August 2009 to October 2012. Predisposing factors for the need of enlargement of the umbilical incision were analysed. Results: Additional enlargement of the umbilical incision for gallbladder removal was required in 35.8% of the patients at skin level, and in 40.4% at fascia level. The median enlargement of the umbilical skin incision was 11 mm, from 25 mm to 36 mm. Gallbladder weight, total stone weight, maximum diameter of largest stone and shorter initial length of incision were independent predisposing factors for enlargement of the incision. Conclusions: In standard laparoscopic cholecystectomy the umbilical incision frequently requires secondary enlargement, especially if a large stone mass is involved. Therefore, the cosmetic result after laparoscopic cholecystectomy depends on more than only the technique used for access and the surgical technique for cholecystectomy should be chosen individually for each patient according to the stone mass.     

Laparoscopic cholecystectomy: a community experience.

Minimally invasive surgery appears to be gaining popularity, and removal of the gallbladder by laparoscopic methods is one such procedure for which there is recent enthusiasm. The concerns about safety, morbidity, and mortality in contrast to standard cholecystectomy are being evaluated. To address these concerns we reviewed the first 230 laparoscopic cholecystectomies done by one surgical group from October 1990 to September 1991. There were 161 women and 69 men with an average age of 50 years. The average length of stay was 2.1 days, most patients being discharged in 24 hours. Complications occurred in 14 patients (6%). The one death was unrelated to the gallbladder surgery. Operative cholangiograms were done as frequently as possible. It appears that laparoscopic cholecystectomy can be done safely and with a shorter hospital stay. Complications are similar to those seen with standard cholecystectomy.     

Failed or difficult laparoscopic cholecystectomy: Can preoperative ultrasonography identify potential problems?

A prospective study was performed to assess the role of preoperative ultrasonography in predicting failed or difficult laparoscopic cholecystectomy. Fifty patients underwent detailed preoperative ultrasound examinations. The number and size of calculi, evidence of acute or chronic cholecystitis, gallbladder morphology, and the presence or absence of aberrant anatomy were documented. A comparison was made of the surgical outcome and the ultrasound findings in each patient. Six patients were converted to open cholecystectomy because of inflammatory changes in the gallbladder. The preoperative ultrasound studies in 5 of these patients demonstrated evidence of cholecystitis and cholelithiasis. Gallbladder wall thickening and contraction were also seen. Five gallbladder resections had intraoperative difficulties; preoperative ultrasonography demonstrated a thickened gallbladder wall in 2. Of 31 uneventful cases, 7 had evidence of gallbladder wall thickening and/or contraction. There were no ultrasound features that identified between the unsuccessful, difficult, or uneventful laparoscopic cholecystectomies. We conclude that detailed preoperative ultrasound evaluation of the gallbladder in patients destined for laparoscopic cholecystectomy is of little value in screening for difficult or unsuitable cases. © 1994 John Wiley & Sons, Inc.     

Single‐port laparoscopic cholecystectomy: A comparative study in 106 initial cases

Introduction: Laparoscopic cholecystectomy has been the standard of care for gallbladder diseases since the late 1980s. Many surgeons have rapidly adopted single‐port laparoscopic cholecystectomy for gallbladder pathologies. The aim of the present study was to analyze the clinical outcome in initial single‐port laparoscopic cholecystectomy. Methods: Data from 106 consecutive single‐port laparoscopic cholecystectomies between May 2008 and April 2009 were analyzed retrospectively. We divided the patients into two groups – an early group (group I, n=56) and a late group (group II, n=50) – to compare clinical outcomes. During each procedure, only one longitudinal transumbilical incision, 1.5 to 2.0 cm in length, was made to access the abdominal cavity. A multichannel port system was assembled with existing devices. Standard laparoscopic instruments were used to perform each cholecystectomy. Results: Patient demographics did not differ between the two groups. Of the eight cases that were converted to conventional laparoscopic surgery, seven were part of group I (P=0.063). Mean operation time for single‐port laparoscopic cholecystectomy was significantly shorter in group II (58.2 versus 71.6 min, P=0.004). There were two operative complications in group I, which were successfully managed with laparoscopic surgery. There was no statistical difference in occurrence of operative complication and hospital stay between the two groups. Conclusion: Single‐port laparoscopic cholecystectomy can be safely performed for various gallbladder lesions in selected cases, and the operation time improved with accumulation of cases.     

腹腔镜胆囊切除即刻中转开腹手术临床分析(附236例报告)

目的：总结腹腔镜胆囊切除术（LC）即刻中转开腹手术的临床经验。方法：回顾分析11436例LC即刻中转开腹的临床资料。结果：LC即刻中转开腹手术的发生率为2.06%，主要原因是急性胆囊炎，近期有急性胆囊炎发作史，胆囊周围粘连，胆囊颈部结石嵌顿，Calot三角解剖不清，难以辨认胆囊管，胆总管损伤。结论：正确掌握中转开腹的时机是降低LC手术并发症的有效措施。提高腹腔镜基本技术，控制手术适应症和必要的辅助检查有利于降低LC中转手术率。     

CT imaging of biliary enteric fistula

Background: To define the signs useful for differentiating between gallbladder–enteric fistula (GB-EF) and common bile duct–enteric fistula (CBD-EF) on computed tomography (CT) because the prognosis and management of the two are different. Methods: CT scans in 13 patients with pneumobilia, who had not had surgical biliary–enteric anastomosis and endoscopic sphincterotomy, were reviewed. The presence of fistula itself, the location of air in the biliary system, and the appearance of the gallbladder were assessed. Results: The causes of pneumobilia were GB-EF in seven patients, CBD-EF in three patients, emphysematous cholecystitis (EC) in one patient, gallbladder cancer (GBC) in one patient, and incompetent sphincter of Oddi in one patient. In three of seven GB-EF patients (43%) and in none of the three CBD-EF patients (0%), the fistula itself was detected. Air was detected in the common bile duct in four of seven GB-EF (57%) and in all three CBD-EF (100%) patients, and GBC. In six of seven GB-EF (86%) and in one of three CBD-EF (33%) patients, the gallbladder was contracted. Thus, the location of air and the contraction of gallbladder were useful signs to differentiate GB-EF from CBD-EF. Conclusion: CT can distinguish between GB-EF and CBD-EF. Received: 17 December 1996/Accepted: 5 February 1997     

58例腹腔镜手术切除复杂性胆囊临床分析

目的研究复杂性胆囊腹腔镜切除的手术处理技巧及安全性。方法对本院2008年8月~2010年9月收治的58例复杂性腹腔镜胆囊切除手术治疗病例进行回顾性分析。结果本组58例病例中1例中转开腹;其余病例均成功完成腹腔镜胆囊切除术无死亡病例。无胆管损伤及严重并发症病例。结论对于复杂性胆囊应重视B超,CT等辅助检查的评估,在正确的术式、熟练的操作以及灵活的技巧等前提下,腹腔镜手术切除复杂性胆囊的安全性毋庸置疑。     

Spontaneous thrombosis of a pseudoaneurysm complicating pancreatitis

Patients with a visceral aneurysm are at high risk for acute transpapillary, intra-, or retroperitoneal hemorrhage, necessitating either surgical or endovascular therapy. We report an instance of spontaneous thrombosis of a pseudoaneurysm complicating pancreatitis before endovascular treatment could be performed. Causality and the literature of spontaneous thrombosis in pseudoaneurysms are discussed. Received: 14 December 1998/Accepted: 13 January 1999     

改良经脐“单孔”腹腔镜胆囊切除术

目的探讨改良的经脐单孔腹腔镜胆囊切除术的临床可行性。方法回顾性分析2009年2月-2012年4月75例患者行改良经脐单孔腹腔镜手术的临床资料。其中39例胆囊结石,20例胆囊息肉,急性胆囊炎14例,急性胆囊炎伴穿孔2例。结果73例手术均成功完成,2例转为传统三孔腹腔镜胆囊切除术后顺利完成手术,无中转开腹。平均手术时间为54．4min（23～120min）。术中出血量5～30mL,平均（14．9±5．10）mL。术后疼痛轻,恢复快,3d后出院。随访1～10个月,未出现出血、漏胆、胆管损伤、消化道损伤、切口疝等并发症。且瘢痕隐蔽,不易发现。结论改良后的经脐单孔腹腔镜胆囊切除术安全可行,具有微创、经济、恢复快等优点,具有推广价值。     

术前超声检查在腹腔镜胆囊切除术中的临床价值简

目的探讨术前超声检查在腹腔镜胆囊切除术中的临床应用价值。方法选择2012年2月至2013年5月接受超声检查后行腹腔镜胆囊切除术的186例患者的超声检查结果、术后病理等资料进行回顾性分析研究。结果术前超声检查对手术难易程度的预测与实际手术难易程度的符合率为97．70％,手术困难组的术后并发症、术中转开腹率、胆囊壁厚度均明显高于非手术困难组（P〈0．05）。结论术前对患者行超声检查可有效对腹腔镜胆囊切除术实际难度进行科学预测,对降低手术并发症、手术中转开腹的发生率具有重要意义。     

腹腔镜胆囊切除术转开腹的危险因素Logistic分析

目的 探讨腹腔镜胆囊切除术转开腹的主要危险因素.方法 回顾分析2009～2011年45例腹腔镜胆囊切除术中转开腹患者的临床资料,根据患者临床症状、体征以及临床指标对中转开腹的主要危险因素进行分析.结果 多因素Logistic回归结果显示,患者的胆囊壁厚度、胆囊炎发作次数、左上腹肌紧张程度、胆囊炎发作到手术时间、血清总胆红素、胆囊三角的清晰度以及墨菲征阳性程度均为胆囊切除术中转开腹的危险因素.结论 手术前对上述危险因素进行综合评估对成功施行腹腔镜胆囊切除术具有重要的临床指导意义.     

Xanthogranulomatous cholecystitis: a radiological study of 12 cases and a review of the literature

Background: Twelve cases of xanthogranulomatous cholecystitis (XGC) are presented, and their radiologic appearance is described. Methods: Four men and eight women, aged 31–82 years old, with XGC were reviewed. Abdominal ultrasound (US) was performed in all patients. Computed tomography (CT) was performed in five patients, barium enema examination in two, and percutaneously CT-guided fine-needle aspirative biopsy of the gallbladder in one. Results: Barium enema examination showed an indentation of the hepatic flexure. Cholelithiasis was present in all patients, and sludge was present in six. The gallbladder wall was thickened in all patients, irregular in nine, and could not be properly differentiated from surrounding liver parenchyma or from other adjacent structures in most patients. A curvilinear halo, hypoechoic on US and with low attenuation on CT, within the gallbladder wall was found in three patients and pericholecystic fluid in two others. On CT, the pericholecystic fat had streaky soft tissue densities in three cases. Percutaneously CT-guided fine-needle aspirative biopsy of the gallbladder was nondiagnostic. The diagnosis of gallbladder carcinoma was considered preoperatively in three patients. Conclusion: Despite the characteristic histologic appearance of XCG, radiologic findings are nonspecific, varying from signs observed in other forms of cholecystitis to the appearance of a gallbladder neoplasm. Received: 5 April 1995/Accepted: 15 May 1995     

B超与腹腔镜胆囊切除术相关性分析

本文探讨腹腔镜胆囊切除术前B超的应用价值,从而预报手术的可行性,以及腹腔镜胆囊切除转为传统胆囊切除的可能因素等,为临床制定治疗方案提供有重要价值的参考依据。     

Gallstones: a choice of treatments]

This article presents a profile of the 20-year evolution in the treatment of gallbladder stones. The author herself works in a modern hepato-biliary and pancreatic surgical department of Hospital Saint-Luc in Montreal. The role of the gallbladder, its pathophysiology and the symptoms of gallbladder syndrome are explained. The main objective of the article is to inform the nurse that, along with traditional surgical treatment, other treatments, non-surgical as well as surgical, do exist. The general public is aware of new methods such as laparoscopic cholecystectomy. This surgical procedure is explained along with other choices of treatment.     

胆囊三角冰冻的腹腔镜胆囊切除术

目的：探讨胆囊三角冰冻的腹腔镜胆囊切除术的手术方法及手术安全性,方法：在常规解剖胆囊三角失败后改为逆行切除,应用腹腔镜逆行胆囊切除的方法对27例因胆囊三角冰冻性粘连,常规解剖胆囊三角失败的胆囊结石病人进行胆囊切除。结果：27例病人中3 病人中转开腹,占11．1％,其余病人腹腔镜手术成功,所有病人术后恢复顺利,无并发症发生,结论：因反复炎症,使胆囊在三角发生冰冻性粘连,腹腔镜逆行胆囊切除是一种安全有效的方法。     

Robot-assisted laparoscopic cholecystectomy: initial Mayo Clinic Scottsdale experience

OBJECTIVE: To review a single institution's experience with robot-assisted laparoscopic cholecystectomy. PATIENTS AND METHODS: We reviewed retrospectively all cholecystectomies performed with the assistance of a surgical robot at the Mayo Clinic in Scottsdale, Ariz, from October 2002 to July 2003. Cholanglograms were obtained intraoperatively for patients with elevated results on liver function tests. The gallbladder was removed by the surgeon with the use of the robot. A surgical assistant at the operating table exchanged instruments in the robot arms and applied clips when needed. Total operating time, assembly time of the robot, complications, and postoperative course were evaluated. RESULTS: Nineteen patients underwent robot-assisted laparoscopic cholecystectomy; 16 had symptomatic cholelithiasis, 2 had gallbladder polyps, and 1 had acute cholecystitis. Of the 19 surgeries, 16 were completed successfully with robotic assistance. In 3 consecutive patients, a mechanical problem occurred with the robot; however, all procedures were completed laparoscopically. The mean set-up time, including patient positioning and preparation and robotic installation, was 28.1 minutes. The mean +/- SD operating time was 82.3+/-17.9 minutes without a cholanglogram and 102+/-20.9 minutes with a cholanglogram. There were no complications and no conversions to an open procedure. CONCLUSION: Robotic surgery offers many potential advantages, including surgeon comfort, elimination of surgeon tremor, improved imaging, and increased degrees of freedom of the operative Instruments, compared with conventional laparoscopic surgery. However, patient outcomes and operative costs need to be evaluated further.