Laparoscopic cholecystectomy is associated with spillage of gall stones in 5%–40% of procedures, but complications occur very rarely. There are, however, isolated case reports describing a range of complications occurring both at a distance from and near to the subhepatic area. This review looks into the various modes of presentation, ways to minimise spillage, treating the complications, and the legal implications.

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A consecutive series of 25 patients who developed external small bowel fistula within 2 weeks of abdominal surgery is described. Half the patients had a primary diagnosis of inflammatory bowel disease and the fistula arose usually as a result of direct trauma to the bowel or the breakdown of an anastomosis. All the patients were treated conservatively with total bowel rest and intravenous hyperalimentation. In 15 (60 per cent) spontaneous fistula closure occurred, in an average period of 32 days. In 8 patients the fistula failed to close and surgery was performed, but was effective in only 3 cases. Thus the fistula eventually closed in 18 patients. Five patients died, all from intra-abdominal sepsis. Of the 8 patients with a primary diagnosis of Crohn's disease, 3 died, 2 have a persistent fistula, 1 has a permanent ileostomy and spontaneous closure occurred in only 2.

Recurrent peptic ulceration was diagnosed in 9 per cent of 433 patients who were treated by elective highly selective vagotomy (HSV) for duodenal ulcer (DU) between 1969 and 1980. In 233 patients followed up for 5-12 years (12 per cent being lost to follow-up), the incidence of recurrence was 10.7 per cent. The site of recurrence was duodenal in 23 patients, pyloric in 4, gastric in 6 and combined duodenal and gastric in 2 (total of 35 patients). One patient presented with a perforation, l4 with haemorrhage and 30 with epigastric pain. Asymptomatic patients were not endoscoped and so asymptomatic recurrence would have been missed. Nine patients were treated by reoperation (5 Polya partial gastrectomy, 4 vagotomy + antrectomy), the remainder with cimetidine. There was no mortality. When the 35 patients with recurrence were compared with the patients without recurrence, no preoperative factors could be identified that might be used to predict recurrence. Thus, for the two groups, the sex distribution, age, length of ulcer history, previous ulcer complications and preoperative acid outputs (basal and maximal) were very similar. This was true also when the data for patients with true recurrence in the duodenum were examined separately. Hence, contrary to some previous reports, no evidence was found that patients who are hypersecretors of acid, either basal or maximal, before operation should be treated by vagotomy combined with antrectomy. After HSV, however, patients with recurrent DU secreted more acid (basal, insulin and pentagastrin-stimulated) than patients without recurrence, the difference between the two groups being statistically significant for basal acid output (BAO) and the response to insulin. The only factor which was found to influence the incidence of recurrent ulceration after HSV strongly was the surgeon who performed the operation.

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