621 Delayed Presentation of Retained Gallstones Post Laparoscopic Cholecystectomy - Complicated by Falciform Ligament Abscess Formation

Case

30-year-old female presented with six days of intermittent epigastric pain, increasing severity, with associated nausea and vomiting. Past history included depression, smoking and a laparoscopic cholecystectomy and intraoperative cholangiogram (IOC) performed interstate 8mths prior for acute cholecystitis. The operation report described a normal IOC, significantly inflamed gallbladder, requiring needle decompression and retrieval of two 15-20mm gallstones from Morison’s pouch.

Investigations showed elevated white cell count(13x10^9/L) and C-reactive protein(56mg/L), with mildly cholestatic liver function tests. Computed Tomography revealed two 1.5cm lesions abutting the inferior margin of the liver; one with shadowing on Ultrasound suspicious for a gallstone, with surrounding inflammatory mass and fat stranding.

A laparoscopic exploration and removal of retained gallstone was performed. Intraoperative findings included adhesions between the gastric body and falciform ligament; with chronic abscess cavity containing pus and a 1.5cm gallstone within the falciform ligament. She recovered well and discharged with antibiotics the next day.

Discussion

Gallstone spillage occurs in 6-40% of laparoscopic cholecystectomies, potentially causing complications (abscess, fistula, or haemorrhage) in 8.5% if retained. Abscess formation (as above) is often recurrent if the gallstone is not removed, thus a laparoscopic technique is preferable.

Attempted removal during surgery and documentation of spilled gallstones in the operation report is imperative to alert medical teams to the possibility of a complication if the patient were to represent. A high level of suspicion aids in the early recognition and intervention; particularly given the time post initial operation and limitations of standard imaging in detection of retained gallstones.