Recurrent abdominal pain after laparoscopic cholecystectomy
CAUSES OF RETAINED GALLBLADDER AND CYSTIC DUCT REMNANT
6. What may have predisposed this patient to a retained gallbladder or cystic duct remnant after her surgery?
- Laparoscopic cholecystectomy
- Not doing intraoperative cholangiography
- Cholecystectomy for acute cholecystitis
- All of the above
All of the above may have contributed.
Postcholecystectomy syndrome can pose a diagnostic and therapeutic challenge, as in our patient. Although it has been reported since the advent of the operation, it is more common after laparoscopic cholecystectomy than after open surgery. One possible cause is stones in a cystic duct remnant, ie, a stub longer than 1 cm.
During open cholecystectomy, the cystic duct is ligated and cut as close to the common bile duct as possible, leaving only a small remnant. In laparoscopic cholecystectomy, it is divided closer to the gallbladder to avoid iatrogenic injury to the common bile duct, leaving a longer remnant. A long cystic duct remnant can be prevented by accurately locating the junction of the gallbladder and the cystic duct during cholecystectomy and by routinely doing intraoperative cholangiography. The presence of stones in a cystic duct or retained gallbladder remnant is a rare cause of postcholecystectomy syndrome, and suspicion is required to make the diagnosis.17–19
We should note that stones may also lurk in the short cystic duct remnant left after open cholecystectomy. In fact, the first case of cystic duct remnant, the so-called reformed gallbladder containing stones, was described in 1912 by Flörcken.20
Intraoperative cholangiography was introduced in 1931 by Mirizzi,21 who recommended its routine use. Since the advent of laparoscopic cholecystectomy in 1988, the routine use of intraoperative cholangiography has been debated. Advocates point to its ability to detect unsuspected calculi and to delineate the biliary anatomy, thus reducing the risk of biliary duct injury.7,22–25 Those who argue against its routine use emphasize the low reported rates of unsuspected stones in the common bile duct (2% to 3%), a longer operative time, the additional cost, and false-positive results that may lead to unnecessary common bile duct exploration. Another argument against its routine use is that most small ductal stones pass spontaneously without significant sequelae.26–28 Surgeons who use intraoperative cholangiography only selectively use it in patients with unclear biliary anatomy and preoperative biochemical or radiologic evidence of choledocholithiasis.
Case continued: She undergoes repeat ERCP
IF STONES ARE DIFFICULT TO EXTRACT
7. If the cystic duct stone were not amenable to endoscopic extraction, what would be the best alternative?
- Extracorporeal shock-wave lithotripsy (ESWL)
- Endoscopic biliary laser lithotripsy
- Repeat laparoscopic cholecystectomy
- All of the above
All of the above are alternatives.
A symptomatic stone in a cystic duct remnant is uncommon and is mentioned in the literature only in case series and case reports.
ESWL is effective for treating bile duct calculi.29 In a cohort of 239 patients with bile duct stones treated by ESWL, Benninger et al30 concluded that endoscopy plus ESWL was a definitive treatment for all patients except one, who subsequently underwent cholecystectomy. Once fragmented, the stones are extracted endoscopically.
Another fragmentation technique that can be offered to patients with stones in the cystic duct that are difficult to extract is contact fragmentation with a holmium laser placed in a transpapillary position under visual guidance.17
Repeat cholecystectomy with removal of stones in the cystic duct remnant (and removal of retained gallbladder remnants and reduction of the cystic duct remnant) has good postoperative results.17,18,31,32
After incomplete cholecystectomy, the cystic duct remnant and the Calot (cystohepatic) triangle are surrounded by inflamed scar tissue, and this was thought to make laparoscopic reoperation difficult.33 However, with advances in surgical technique and increasing experience of surgeons, repeat cholecystectomy can be done laparoscopically. It has now been suggested that laparoscopic exploration to remove the gallbladder remnants is safe and feasible in such patients.34,35
Discharge and follow-up
The patient is discharged home after the procedure. She is still free of symptoms 31 months later.
