Perfoation of the gallbladder: ‘bait’ for the unsuspecting laparoscopic surgeon

Abstract

INTRODUCTION Cholecystectomy is one of the most common elective procedures carried out by general surgeons. Most patients present with typical biliary anatomy and simple gallstone disease. Intraoperative and postoperative courses are frequently predictable and uncomplicated. Nevertheless, a small but significant number of patients experience complicated disease with rare presentations and complex biliary anatomy. Unfortunately, consensus on appropriate care for such patients is lacking. CASE HISTORY We describe three patients who presented with complex manifestations of gallbladder perforation: acute perforation of the gallbladder; a spontaneous cholecystocutaneous fistula; a cholecystoduodenal fistula. The initial presentation, preoperative investigations, and selected surgical strategy for each case are described. CONCLUSIONS The case studies described here illustrate the need for a low index of suspicion for gallbladder perforation. Caution should be exercised in preoperative and intraoperative phases in this patient population.

Cholecystocutaneous fistula incidence, Etiology, Clinical Manifestations, Diagnosis and treatment. A literature review

“… MRCP ERCP and sphincterotomy Yüceyar et al [ 36 ] 70 F Gallstones abscess formation in the right upper quadrant _ Open cholecystectomy Carragher et al [ 37 ] 67 F Gallstones Right hypochondrial pain CT Conservative management Hoffman et al [ 38 ] 70 F Gallstones chronic epigastric pain. During the surgery Open cholecystectomy and choledocholithotomy 73 F Gallstones ten-day history of dull epigastric pain and anorexia During the surgery Laparotomy Jeffery et al [ 39 ] _ M Gallstones enlarging mass on the right upper abdomen During the surgery Open cholecystostomy Schippers et al [ 40 ] 75 M Cholecystitis _ _ _ Gerrard et al [ 22 ] 80 F Cholecystitis acute cholecystitis CT Percutaneous cholecystectomy Mughal et al [ 19 ] 74 <...>…”

“… During the surgery Open cholecystectomy and choledocholithotomy 73 F Gallstones ten-day history of dull epigastric pain and anorexia During the surgery Laparotomy Jeffery et al [ 39 ] _ M Gallstones enlarging mass on the right upper abdomen During the surgery Open cholecystostomy Schippers et al [ 40 ] 75 M Cholecystitis _ _ _ Gerrard et al [ 22 ] 80 F Cholecystitis acute cholecystitis CT Percutaneous cholecystectomy Mughal et al [ 19 ] 74 F Cholecystitis unremitting pain in the right shoulder that had progressed to the right side of the abdomen During the surgery Open cholecystectomy pain and swelling in the RUQ, and development of a discharging sinus within it US + CT Open cholecystectomy Maynard et al [ 7 ] 68 F Cholecystitis painful swelling in the right upper anterior abdominal wall. CT Open cholecystectomy Jayasinghe et al [ 41 ] 87 F ...…”

“…However, patients may present with pain and swelling in the RUQ or epigastric region [ [6] , [18] ], discharging sinus from the anterior abdominal wall [ [15] , [19] ], erythematous mass [ 20 ], subcostal abscess [ 18 ] ( Table .1 ). The most common site of external opening is in the right upper quadrant of the abdominal wall.…”

“…US provides good assessment for CCF diagnosis by showing abnormal findings such as abscess, gallbladder stones, edema, thickened in gallbladder wall and dilated biliary ducts [ [5] , [15] , [17] , [21] ] but often fails to confirm the CCF diagnosis. In a few cases, US was able to demonstrate the track of CCF [ [12] , [19] ].…”

“…Furthermore, CT fistulogram can also show the track of CCF which confirm the diagnosis [ 21 ]. CT couldn't identify the track of CCF in a few cases where it just showed abnormal findings which point toward the diagnosis [ [19] , [23] , [26] , [27] ].…”