Laparoscopic management of chronic abscess due to spilled gallstones.

INTRODUCTION: Bile and gallstones are spilled during 13% to 40% of all laparoscopic cholecystectomies. They can act as a septic focus and cause complications. We present 2 cases of perihepatic abscess formation due to dropped gallstones presenting some years later. Delayed diagnosis resulted in unnecessary investigations and had negative economic consequences.

CASE DESCRIPTION: In 1 patient a posterolateral cutaneous fistula had developed that was initially biopsied by cardiothoracic surgeons before computed tomography showed the cause. The other patient presented with recurrent Pyrexia of unknown origin (PUO) causing repeated absence from work and was diagnosed only after 18 months of medical investigation. Both patients were treated with laparoscopic drainage of the abscess and successful retrieval of all stones.

DISCUSSION: Radiologic and open drainage and retrieval of stones have been well described in these cases. We suggest that a laparoscopic approach is superior because the cavity can be clearly identified and stones visualized and removed under direct vision. The need for a formal laparotomy is avoided. We also highlight the economic burden to both patient and health care professional of delayed diagnosis, as shown in these 2 cases. Spilled gallstones are a recognized complication of laparoscopic cholecystectomy. All stones should be actively sought and removed to avoid complications. Laparoscopic drainage is preferable to open or radiologic drainage. Dropped gallstones should be considered a possible diagnosis in patients who have had a previous cholecystectomy and present with unusual symptoms.