The Pucker sign: an operative and radiological indicator of impending operative difficulty due to severe chronic contractive inflammation in cholecystectomy.

INTRODUCTION

Marked inflammatory contraction of the gallbladder at the time of cholecystectomy is associated with biliary injury.

METHODS

The evolution of contraction is traced in two patients who developed acute cholecystitis.

RESULTS

Within months the gallbladder became fibrotically contacted and in doing so pulled the adjacent liver down, puckering the surface of the liver. This puckering could be observed preoperatively on computed tomography and also visually at the time of surgery.

CONCLUSIONS

Puckering of the liver ("Pucker sign") can alert the surgeon to the presence of severe contractive inflammation.