de la colecistectomía laparoscópica
Surg Endosc 2001 Jan;15(1):98
Wolf in sheep's clothing: spilled gallstones can cause severe
complications after endoscopic surgery.
Gretschel S, Engelmann C, Estevez-Schwarz L, Schlag PM.
Department of Surgery and Surgical Oncology, Robert Rossle Hospital,
Humboldt University, Lindenbergerweg 80, D-13122 Berlin, Germany.
Bile concrements may remain intraperitoneally after laparoscopic
cholecystectomy. Previously, this was considered harmless, a view
supported by some experimental studies. Recently, however, spilled
gallstones have been identified as a source of rare but potentially
serious complications. We report a case of a retrohepatic abscess and
dorsal fistulation after laparoscopic cholecystectomy. Healing was
achieved only by repeated surgery, including abscess drainage, stone
removals, and fistula excision. Since 1990, 73 cases with gallstone-related
complications after laparoscopic cholecystectomy have been reported in the
literature. Among these complications, intra-abdominal abscesses and
transabdominal fistulas were predominant. The interval between the
cholecystectomy and the appearance of complications ranged from 4 days to
29 months, with a peak incidence at 4 months. Spillage of small bile
concrements or fragments is, with the exception of multiple irremovable
stones, not commonly an indication for conversion to an open procedure.
However, the patient needs to be warned about the risk of gallstone loss
and its associated complications at the time when informed consent is
obtained. Furthermore, if gallstone loss has occurred, the patient should
be informed, and the occurrence should be documented.
2: Clin Imaging 2000 Jul-Aug;24(4):204-6
Perforation of the small bowel as a complication of laparoscopic
cholecystectomy: CT findings.
Ho AC, Horton KM, Fishman EK.
The Russell H. Morgan Department of Radiology and Radiological Science,
The Johns Hopkins Medical Institution, 600 North Wolfe Street, 21287,
Baltimore, MD, USA
Despite the widespread use of laparoscopic cholecystectomy, technical
complications unique to the laparoscopic approach may lead to significant
postoperative morbidity and mortality. We report a rare case of small
bowel perforation due to trocar injury that led to extensive
pneumoperitoneum and pneumomediastinum in a patient who underwent
laparoscopic cholecystectomy. Small bowel injuries should be suspected
when a large or an increasing amount of free air is detected following
3: Surg Today 2000;30(3):277-81
Nonspecific ulcerated jejunitis as an unusual complication of laparoscopic
cholecystectomy: report of a case.
Akkus MA, Cetinkaya Z, Ilhan YS, Caboglu SA, Bulbuller N.
School of Medicine, Department of General Surgery, Firat University,
We describe herein the case of a 65-year-old man in whom a lower
gastrointestinal hemorrhage developed a few days after he underwent an
elective laparoscopic cholecystectomy. A laparotomy was performed on
postoperative day 16 and a jejunal segment containing mucosal changes and
oozing ulcers was resected. Pathologic examination of the specimen
revealed "nonspecific ulcerated jejunitis." There is no
explanation for the etiopathogenesis of this pathology; however, we
concluded that this clinical picture may be attributed to ischemia-reperfusion
injury that occurred following an ischemic period caused by the
pneumoperitoneum during laparoscopic surgery.
4: Dig Surg 2000;17(5):542-4
Embolism of a metallic clip: an unusual complication following
Ammann K, Kiesenebner J, Gadenstatter M, Mathis G, Stoss F.
Department of General Surgery, University Hospital, Innsbruck, Austria.
A 32-year-old woman underwent laparoscopic cholecystectomy during which
there was severe bleeding from the bed of the gallbladder. As application
of metallic clips to control the bleeding was not successful, the
operation was converted to an open laparotomy. Cholecystectomy was
successfully completed without further complications, and the post-operative
course was uneventful and the patient was discharged. Eighteen months
later, the patient complained of dyspnea. Plain radiograph and computed
tomography of the thorax showed a metallic clip in the branch of the
pulmonary artery supplying the posterior basal segment of the inferior
lobe of the left lung. There was no connection between the patient's
symptoms and the clip embolism. Nevertheless, clip migration or embolism
could cause severe complications. Therefore, metallic clips should not be
used to stop bleeding from the gallbladder bed. Copyright 2000 S. Karger
5: HPB Surg 2000 Aug;11(6):373-8
Cholecystectomy, conversion and complications.
Thompson MH, Benger JR.
The Department of Surgery, Southmead Hospital, Bristol, United Kingdom.
BACKGROUND: Faced with a difficult laparoscopic cholecystectomy the
surgeon may feel that conversion to open operation would risk greater
complications because of the laparotomy. Information on the effect of
conversion is lacking. The purpose of this study is to measure the
complications of laparoscopic cholecystectomy and observe the effect of
the conversion rate. METHODS: A total of 957 patients were studied. There
were three consecutive series of patients; the first undergoing open
cholecystectomy (384 patients), the second laparoscopic cholecystectomy
with a 5.8% conversion rate (412 patients) and the third laparoscopic
cholecystectomy with a 1.3% conversion rate (161 patients). Data was
collected prospectively using a continuous audit, and the complication
rate compared on an intention to treat basis. In addition a panel of
experienced surgeons was asked to score the complications depending on
their severity and a composite complication score calculated. Comparison
between the 3 groups was then undertaken. RESULTS: Open cholecystectomy
produced a post-operative complication rate of 6%. Initially this appeared
to fall to 3.1% with the introduction of laparoscopic cholecystectomy, but
when the complications occurring in the converted patients were included
(i.e., on an intention to treat basis) the rate increased to 5.6% in the
first group of laparoscopically-treated patients and 3.1% in the second.
These differences were not statistically significant. A similar pattern
emerged when scoring the severity of the complications as judged by the
expert panel. The inclusion of intra-operative complications appears to
remove any small advantage for laparoscopic cholecystectomy. The reduction
in the conversion rate between the two laparoscopic groups from 5.8% to
1.2% was statistically significant. CONCLUSION: When considered on an
intention to treat basis laparoscopic cholecystectomy offers no advantage
over open operation in terms of the frequency or severity of complications.
Reducing the frequency of conversion from a laparoscopic to an open
procedure also has no significant effect on the complications encountered.
We conclude, therefore, that the complication rate is independent of the
conversion rate and that the surgeon, when faced with difficulty at
laparoscopic cholecystectomy, should not be deterred from converting to
open operation for fear of the post-operative consequences.
6: Surg Endosc 2000 Aug;14(8):755-60
Laparoscopic cholecystectomy for acute cholecystitis: can the need for
conversion and the probability of complications be predicted? A
Brodsky A, Matter I, Sabo E, Cohen A, Abrahamson J, Eldar S.
Department of Surgery, Bnai Zion Medical Center, the Faculty of Medicine,
and the Faculty of Industrial Engineering and Management, the Technion,
Israel Institute of Technology 47 Golomb Street, Post Office Box 4940,
Haifa 31048, Israel.
BACKGROUND: Laparoscopic cholecystectomy (LC) in acute cholecystitis is
associated with a relatively high rate of conversion to an open procedure
as well as a high rate of complications. The aim of this study was to
analyze prospectively whether the need to convert and the probability of
complications is predictable. METHODS: A total of 215 patients undergoing
LC for acute cholecystitis were studied prospectively by analyzing the
data accumulated in the process of investigation and treatment. Factors
associated with conversion and complications were assessed to determine
their predictive power. RESULTS: Conversion was indicated in 44 patients
(20.5%), and complications occurred in 36 patients (17%). Male gender and
age >60 years were associated with conversion, but these factors had no
sensitivity and no positive predictive value. The same factors, together
with a disease duration of >96 h, a nonpalpable gallbladder, a white
blood count (WBC) of >18,000/cc(3), and advanced cholecystitis,
predicted conversion with a sensitivity of 74%, a specificity of 86%, a
positive predictive value of approximately 40%, and a negative predictive
value of 96%. However, these data became available only when LC was
underway. Male gender and a temperature of >38 degrees C were
associated with complications, but these factors had no sensitivity and no
positive predictive value. Progression along the stages of admission and
therapy did not add predictive factors or improve the predictive
characteristics. Male gender, abdominal scar, bilirubin >1 mg%,
advanced cholecystitis, and conversion to open cholecystectomy were
associated with infectious complications. Their sensitivity and positive
predictive value remained 0 despite progression along the stages of
admission and therapy. CONCLUSION: Although certain preoperative factors
are associated with the need to convert a LC for acute cholecystitis, they
have limited predictive power. Factors with higher predictive power are
obtained only during LC. The need to convert can only be established
during an attempt at LC. Preoperative and operative factors associated
with total and infectious complications have no predictive power.
7: Eur J Surg 2000;Suppl 585:18-21
Complications of laparoscopic cholecystectomy as recorded in the Swedish
Department of Surgery, Lanssjukhuset, Kalmar, Sweden.
The Swedish laparoscopy registry prospectively recorded 11,164
laparoscopic cholecystectomies during the years 1991-1993 with the aim of
monitoring bile duct injuries and other complications of the new technique.
In total 57 bile ducts were injured; 35 of these were merely incision of
the common bile duct. Serious injuries with tissue loss occurred in 11
cases and clipping or electrocautery damage in another 11.
8: Rev Hosp Clin Fac Med Sao Paulo 1999 Nov-Dec;54(6):209-12 [Texto
Elimination of biliary stones through the urinary tract: a complication of
the laparoscopic cholecystectomy.
Castro MG, Alves AS, Oliveira CA, Vieira Junior A, Vianna JL, Costa RF.
Division of General Surgery, Felicio Rocho Hospital, Belo Horizonte,
The introduction and popularization of laparoscopic cholecystectomy has
been accompanied with a considerable increase in perforation of
gallbladder during this procedure (10% - 32%), with the occurrence of
intraperitoneal bile spillage and the consequent increase in the incidence
of lost gallstones (0.2% - 20%). Recently the complications associated
with these stones have been documented in the literature. We report a rare
complication occurring in an 81-year-old woman who underwent laparoscopic
cholecystectomy and developed cutaneous fistula to the umbilicus and
elimination of biliary stones through the urinary tract. During the
cholecystectomy, the gall bladder was perforated, and bile and gallstones
were spilled into the peritoneal cavity. Two months after the initial
procedure there was exteriorization of fistula through the umbilicus, with
intermittent elimination of biliary stones. After eleven months, acute
urinary retention occurred due to biliary stones in the bladder, which
were removed by cystoscopy. We conclude that efforts should be
concentrated on avoiding the spillage of stones during the surgery, and
that no rules exist for indicating a laparotomy simply to retrieve these
9: Am J Surg 2000 Apr;179(4):316-9
Relaparoscopy for the detection and treatment of complications of
Dexter SP, Miller GV, Davides D, Martin IG, Sue Ling HM, Sagar PM, Larvin
M, McMahon MJ.
Leeds Institute for Minimally Invasive Therapy, Centre for Digestive
Diseases, and the University of Leeds, Wellcome Wing, The General
Infirmary, Leeds, UK.
BACKGROUND: Laparotomy remains the commonest intervention in patients with
abdominal complications of laparoscopic surgery. Our own policy is to
employ relaparoscopy to avoid diagnostic delay and unnecessary laparotomy.
The results of using this policy in patients with suspected
intra-abdominal complications following laparoscopic cholecystectomy are
reviewed. METHODS: Data were collected from laparoscopic cholecystectomies
carried out by five consultant surgeons in one center. Details of
relaparoscopy for complications were analyzed. RESULTS: Thirteen patients
underwent relaparoscopy within 7 days of laparoscopic cholecystectomy for
intra-abdominal bleeding (2 patients) or abdominal pain (11 patients). The
causes of pain were subhepatic haematoma (1), acute pancreatitis (1),
small bowel injury (1), and minor bile leakage (6). In 2 patients no cause
was identified. Twelve patients were managed laparoscopically and 1
patient required laparotomy. Median stay after relaparoscopy was 7 days (range
2 to 19). CONCLUSIONS: Exploratory laparotomy can be avoided by prompt
relaparoscopy in the majority of patients with abdominal complications of
10: Surg Endosc 2000 Apr;14(4):373-4
Is the loss of gallstones during laparoscopic cholecystectomy an
Gerlinzani S, Tos M, Gornati R, Molteni B, Poliziani D, Taschieri AM.
Divisione di Chirurgia Generale II, Universita degli Studi di Milano,
Ospedale Luigi Sacco, Cattedra di Chirurgia Generale, Via G. B. Grassi 74,
20157 Milan, Italy. firstname.lastname@example.org
Laparoscopic cholecystectomy entails an increased risk of gallbladder
rupture and consequent loss of stones in the abdominal cavity. Herein we
report the case of a 51-year-old male patient, who underwent laparoscopic
cholecystectomy 2 years before presentation to our hospital. He had
experienced tension sensation and epigastric pain since 4 months
postoperatively. A well-defined epigastric mass, which was hard and
painful on palpation, was detected and later confirmed by ultrasonography
and CT scan.Explorative laparotomy revealed a mass in the area of the
gastrocolic ligament,resulting from biliary gallstones in conjunction with
a perimetral inflammatory reaction. A review of the literature showed that
the incidence of gallbladder lesions during laparoscopy is 13-40%. In
order to prevent this complication, meticulous isolation of the
gallbladder, proper dissection of the cystic duct and artery, and careful
extraction through the umbilical access are required. Ligation after the
rupture or use of an endo-bag may be helpful. The loss of gallstones and
their retention in the abdominal cavity should be noted in the description
of the surgical procedure.
11: AJR Am J Roentgenol 2000 May;174(5):1441-5
Radiologic features of complications arising from dropped gallstones in
laparoscopic cholecystectomy patients.
Morrin MM, Kruskal JB, Hochman MG, Saldinger PF, Kane RA.
Department of Radiology, Beth Israel Deaconess Medical Center, Harvard
Medical School, Boston, MA 02215, USA.
OBJECTIVE: Because laparoscopic cholecystectomy has become the accepted
treatment for symptomatic cholelithiasis, radiologists frequently
encounter patients who have had this surgery. Although the radiologic
features of postoperative bile duct injury are well documented, the
imaging features of less well-known complications remain poorly described.
One such unusual complication is abscess formation caused by dropped
gallstones. CONCLUSION: Although the incidence of dropped gallstones is an
uncommon complication of laparoscopic cholecystectomy, it should be
recognized as a potential source of both intraabdominal and intrathoracic
abscess formation in any patient presenting months to years after
undergoing laparoscopic cholecystectomy. These abscesses are not
necessarily confined to the right upper quadrant.
12: Am Fam Physician 2000 Mar 15;61(6):1673-80, 1687-8 [Texto
Management of gallstones and their complications.
Ahmed A, Cheung RC, Keeffe EB.
Stanford University School of Medicine, California, USA.
The accurate differentiation of gallstone-induced biliary colic from other
abdominal disease processes is the most crucial step in the successful
management of gallstone disease. Despite the availability of many imaging
techniques to demonstrate the presence of gallstones, clinical judgment
ultimately determines the association of symptoms with cholelithiasis and
its complications. Adult patients with silent or incidental gallstones
should be observed and managed expectantly, with few exceptions. In
symptomatic patients, the intervention varies with the type of gallstone-induced
complication. In this article, we review the salient clinical features,
diagnostic tests and therapeutic options employed in the management of
gallstones and their complications.
13: Eur J Surg 2000 Feb;166(2):136-40
Laparoscopic cholecystectomy for acute cholecystitis: how do fever and
leucocytosis relate to conversion and complications?
Halachmi S, DiCastro N, Matter I, Cohen A, Sabo E, Mogilner JG, Abrahamson
J, Eldar S.
Department of Surgery, Bnai Zion Medical Center and the Faculty of
Medicine, Technion, Israel Institute of Technology, Haifa.
OBJECTIVE: To find out whether fever and raised white cell count (WCC) are
associated with conversion and complications of laparoscopic
cholecystectomy in acute cholecystitis, and whether their presence could
help in deciding the place of laparoscopic procedures. DESIGN: Prospective
study. SETTING: Teaching hospital, Israel. SUBJECTS: 256 patients who were
treated for clinical acute cholecystitis between January 1994 and November
1997. INTERVENTIONS: Emergency laparoscopic cholecystectomy. MAIN OUTCOME
MEASURES: Raised temperature and WCC; incidence of conversion and
complications. RESULTS: Raised temperature (>38 degrees C) was
independently associated with advanced cholecystitis (p = 0.002, odds
ratio [OR] 2.7) and a palpable gallbladder preoperatively (p = 0.02, OR
2.1). Total complications correlated with a temperature of >38 degrees
C. Raised WCC (>15 x 10(9)/L) was independently associated with age
>45 years (p = 0.02, OR 2.4), a palpable gallbladder preoperatively (p
= 0.001, OR 2.9), and a raised temperature (>38 degrees C) (p <
0.0001, OR 6.2). Conversion was associated with a WCC >18 x 10(9)/L (p
= 0.0, OR 3.2). CONCLUSION: A WCC of >18 x 10(9)/L may assist in
predicting conversion, and fever of >38 degrees C may assist in
predicting the development of complications.
14: Br J Surg 2000 Mar;87(3):362-73
Biliary complications associated with laparoscopic cholecystectomy:
analysis of common misconceptions
Bingham J, McKie LD, McLoughlin J, Diamond T.
Mater Hospital, Belfast, UK.
AIMS: General surgeons often express the view that the majority of biliary
complications following laparoscopic cholecystectomy are caused by trainee
surgeons; complications occur most often in the presence of difficult
anatomy or pathology; biliary injuries occur more proximally in the
biliary tree than at open cholecystectomy; most injuries are recognized at
the time of surgery; and most complications can be managed non-operatively.
The aim of this study was to determine if these views are substantiated in
clinical practice. METHODS: Thirty consecutive patients were referred to a
specialist hepatobiliary unit over a 7-year period with biliary
complications following laparoscopic cholecystectomy. The mode of
presentation, management and outcome of these patients were analysed.
RESULTS: In 21 cases the initial operator was a consultant. Four of the 30
complications occurred in the presence of an anatomical variation or
unusually difficult pathology. Only patients in whom a previous attempt at
repair had been made had injuries at or proximal to the bile duct
confluence; the only two deaths occurred in this group. Only 41 per cent
of injuries were detected at the time of surgery and 89 per cent required
further surgical intervention, hepaticojejunostomy being the most common
procedure performed (75 per cent). CONCLUSIONS: The majority of bile duct
injuries are not caused by trainees, do not occur because of unusual
anatomy or pathology, do not occur in the proximal biliary tree, are not
recognized at the time of the initial operation and often require major
reconstructive procedures for their management.
15: Endoscopy 2000 Jan;32(1):S3
Surgical clips incorporated into a duodenal ulcer: a rare complication
after elective laparoscopic cholecystectomy.
Dept. of Surgery, Hospital Nossa Senhora da Saude, Santo Antonio da
Platina, Parana, Brazil. email@example.com
16: Abdom Imaging 2000 Mar-Apr;25(2):190-3
Complications of "dropped" gallstones after laparoscopic
cholecystectomy: technical considerations and imaging findings.
Bennett AA, Gilkeson RC, Haaga JR, Makkar VK, Onders RP.
Department of Diagnostic Radiology, University Hospitals of Cleveland,
Case Western Reserve University School of Medicine, Cleveland, OH 44106,
New laparoscopic techniques have revolutionized the practice of surgery.
Laparoscopic cholecystectomy has become one of the most commonly performed
surgeries worldwide. Although shorter hospital stays and patient comfort
have offered clear advantages over open cholecystectomy, the technique has
resulted in several specific complications, including bile duct injury and
gallbladder perforation. Although rarely clinically significant,
intraperitoneal gallstone spillage can cause abscess formation and
adhesions. Although these patients can present with a confusing clinical
picture, their characteristic radiologic features should be recognized. We
present two cases of complicated intraperitoneal gallstone spillage
radiologically diagnosed and treated with laparoscopic and interventional
17: Br J Radiol 1999 Feb;72(854):201-3
Peritoneal abscess formation as a late complication of gallstones spilled
during laparoscopic cholecystectomy.
Frola C, Cannici F, Cantoni S, Tagliafico E, Luminati T.
Department of Radiology, Ospedale Evangelico Internazionale, Genova, Italy.
The case is described of a 74-year-old woman who presented with an
abdominal abscess 1.5 years after laparascopic cholecystectomy. CT and
ultrasound showed the presence of gallstones within the abscess. Spillage
of gallstones from perforation of the gallbladder is a well recognized
complication of laparascopic cholecystectomy, although subsequent abscess
formation is unusual especially after a long delay as in this case.
18: Ann Surg 1999 Apr;229(4):449-57
Complications of cholecystectomy: risks of the laparoscopic approach and
protective effects of operative cholangiography: a population-based study.
Fletcher DR, Hobbs MS, Tan P, Valinsky LJ, Hockey RL, Pikora TJ, Knuiman
MW, Sheiner HJ, Edis A.
Department of Surgery, University of Western Australia and Fremantle
BACKGROUND: Previous studies suggest that laparoscopic cholecystectomy
(LC) is associated with an increased risk of intraoperative injury
involving the bile ducts, bowel, and vascular structures compared with
open cholecystectomy (OC). Population-based studies are required to
estimate the magnitude of the increased risk, to determine whether this is
changing over time, and to identify ways by which this might be reduced.
METHODS: Suspected cases of intraoperative injury associated with
cholecystectomy in Western Australia in the period 1988 to 1994 were
identified from routinely collected hospital statistical records and lists
of persons undergoing postoperative endoscopic retrograde
cholangiopancreatography. The case records of suspect cases were reviewed
to confirm the nature and site of injury. Ordinal logistic regression was
used to estimate the risk of injury associated with LC compared with OC
after adjusting for confounding factors. RESULTS: After the introduction
of LC in 1991, the proportion of all cholecystectomy cases with
intraoperative injury increased from 0.67% in 1988-90 to 1.33% in 1993-94.
Similar relative increases were observed in bile duct injuries, major bile
leaks, and other injuries to bowel or vascular structures. Increases in
intraoperative injury were observed in both LC and OC. After adjustment
for age, gender, hospital type, severity of disease, intraoperative
cholangiography, and calendar period, the odds ratio for intraoperative
injury in LC compared with OC was 1.79. Operative cholangiography
significantly reduced the risk of injury. CONCLUSION: Operative
cholangiography has a protective effect for complications of
cholecystectomy. Compared with OC, LC carries a nearly twofold higher risk
of major bile, vascular, and bowel complications. Further study is
required to determine the extent to which potentially preventable factors
contribute to this risk.
19: Surgery 1999 Feb;125(2):223-31
Laparoscopic and open cholecystectomy in New York State: mortality,
complications, and choice of procedure.
Hannan EL, Imperato PJ, Nenner RP, Starr H.
Department of Health Policy, Management and Behavior, State University of
New York, Albany, USA.
BACKGROUND: With the advent of laparoscopic cholecystectomy patient
outcomes and choice of procedure (laparoscopic vs open) are of vital
interest. The purpose of this study was to examine the mortality and
complication rates for patients undergoing laparoscopic and open
cholecystectomy in New York State and to test for differences among
hospital peer groups and regions of the state in the tendency to use the
laparoscopic approach. METHODS: A population-based, retrospective cohort
study of laparoscopic and open cholecystectomy was conducted in which data
were analyzed on all 30,968 patients who underwent cholecystectomy as a
principal procedure in New York State in 1996. RESULTS: A total of 78.7%
of the 30,968 patients who underwent cholecystectomy as a principal
procedure in New York State in 1996 underwent laparoscopic cholecystectomy.
The mortality rate was lower for laparoscopic cholecystectomy than for the
open procedure (0.23% vs 1.90%, P < .0001) and remained significantly
lower after patient characteristics related to patient survival (odds
ratio 0.34, P < .0001) were controlled for. The prevalence rate of the
8 most common complications among cholecystectomy patients was also much
lower among patients undergoing laparoscopic cholecystectomy. Patients
undergoing cholecystectomy in public hospitals, Bronx County, and Kings
County were found to be significantly less likely to have laparoscopic
procedures, and patients undergoing cholecystectomy on Long Island were
found to be significantly more likely to have laparoscopic procedures than
were other patients in the state. CONCLUSIONS: There are reasonably large
differences among hospitals, hospital groups, and regions of the state in
the type of cholecystectomy used, even after adjustment for differences in
patient comorbidities and indications for type of procedure.