Lost Stones During Laparoscopic Cholecystectomy

Background: Gallbladder perforation, with loss of calculi in the abdomen is frequent during laparoscopic cholecystectomy. Recent publications report complications in port sites or in the abdominal cavity. A study of 3686 laparsocopic cholecystectomies performed by 6 surgeons was undertaken. In 627 patients, perforation of the gallbladder occurred and in 254 stones were spilled into the abdominal cavity. In 214 they were retrieved and in 40 left in the abdomen. Twelve patients developed complications. Percutaneous drainage was successful in 2 with serous collections. Two patients with abdominal abscesses were reoperated, stones retrieved and the abdomen drained. One patient developed an intestinal obstruction due to a stone in the ileum. One patient who had a cholecystectomy in another hospital developed a paraumbilical tumor. At reoperation a stone was retrieved. In another six patients, stones were found in port sites. Stones lost into the abdomen should be removed because of their potential morbidity, especially if they are large or if infection is present in the gallbladder at the time of initial surgery. There is no indication for routine conversion to open surgery when stone spillage occurs, although patients should be informed to avoid legal consequence, and to hasten early diagnosis of later complications.

Background: Gallbladder perforation, with loss of calculi in the abdomen is frequent during laparoscopic cholecystectomy. Recent publications report complications in port sites or in the abdominal cavity. A study of 3686 laparsocopic cholecystectomies performed by 6 surgeons was undertaken. In 627 patients, perforation of the gallbladder occurred and in 254 stones were spilled into the abdominal cavity. In 214 they were retrieved and in 40 left in the abdomen. Twelve patients developed complications. Percutaneous drainage was successful in 2 with serous collections. Two patients with abdominal abscesses were reoperated, stones retrieved and the abdomen drained.
One patient developed an intestinal obstruction due to a stone in the ileum. One patient who had a cholecystectomy in another hospital developed a paraumbilical tumor. At reoperation a stone was retrieved. In another six patients, stones were found in port sites. Stones lost into the abdomen should be removed because of their potential morbidity, especially if they are large or if infection is present in the gallbladder at the time of initial surgery. There is no indication for routine conversion to open surgery when stone spillage occurs, although patients should be informed to avoid legal consequence, and to hasten early diagnosis of later complications.

INTRODUCTION
Gallbladder disruption with stones falling into the peritoneal cavity was rare during open cholecystectomy, but is frequent in laparoscopic cholecystectomy. Retrieval of stones is difficult during laparoscopic cholecystectomy.
Early reports on laparoscopic cholecystectomy stated that stones, left in the peritoneal cavity, had no deleterious effect [26,31]. More recently as a consequence of spilled stones sepsis, adhesions and fistulae into abdominal organs or port tracts have been described [3,6,8,14,15]. In this paper we assessed the morbidity caused by stones abandones in the abdomen or port tracts.

METHODS
In a retrospective study the records of 3686 patients submitted to laparoscopic cholecystectomy operated by 7 surgeons using similar *Corresponding to: J. Diez operative techniques between 1992 and 1995 were reviewed. Perforation of the gallbladder with spillage of stones and reports if they were retrieved or abandoned in the abdominal cavity were recorded in the operative records and in a special form recomended for laparoscopic biliary ,surgery by the Laparoscopic Commitee of the Argentine Asociation of Surgery. The gallbladder was extracted though the umbilical incision in all patients.
Ultrasonography, CT scans and fistulographies were the methods used in detection of stones.

RESULTS
Perforation of the gallbladder occurred in 627 cases (17%) and in 254 (6.9%) stones spilled into the abdominal cavity. In 214 patients (5.8%) the stones were retrieved but in 40 (1%) the calculi were abandoned in the abdomen (Tab. I). Of these 12 developed complications. In 5 patients, the gallstones presented with intraabdominal problems. Four developed abdominal collections, two serous and two purulent. Six other patients in which no stones were abandoned had post-operative abdominal collections. In 3 bile was responsible and the other 3 were due to blood. All patients recovered with percutaneous drainage [3] or reoperation [3]. One patient had a small bowel obstruction due to a stone lost in the abdomen which entered into the ileum (Tab. II). In 7 patients the stones appeared in fistulous tracts in port sites: 6 at the umbilicus and 1 in a subxiphoid location. In one patient fistulography revealed communication with the transverse colon.  TREATMENT In 2 patients the serous collections were evacuated percutaneously and the stone left in place.
The patients remain asymptomatic for 1 and 2 years respectively. In the 2 cases with purulent abscesses a laparotomy was performed, the abdominal cavity drained and the stones retrieved. An emergency operation was performed for the intestinal obstruction, and a large stone was found in the terminal ileum. The stone was removed and the perforation closed (Tab. III).
Of the 7 patients with stones in sinus or fistula tracts, in 4 the stones were retrieved at the skin and in 3 of them a surgical exploration was performed to extract the stones. All fistulous tracts and the colonic fistulae closed spontaneously (Tab. IV).
A variety of techniques and instruments are available to extract stones: ligature or clips on the gallbladder wall [20] aspiration of the small stones, [26] Dormia Baskets [14,26] bags [13] finger gloves or condom [11,13]. A 30 degree laparoscope is useful, it allows a better view of the reces between the bowel and the liver. Using those methods in 40 of our patients (1%) stones were lost in the abdomen and 12 of them caused complictions (25%).
Symptoms appeared from days to several months after the operation [3,10]. Fever, pain and infection are common [1,4].
The seriousness of the complications is different if the stones are in the abdominal cavity or in the port tracts.
Intraabdominal stones, produce serous or purulent collections and may cause generalized peritonitis, depending of the size of the stones [8,21] and degree of bacterial contamination [33,24]. Large or pigmented stones [3,21] are more likely to produce these complications. Welch [27] in an experimental study demonstrated that some stones can shrink and even be reabsorbed. This might explain why many patients with lost stones remain asymptomatic.
Serous collections can be cured by percutaneous drainage, leaving the stones in the abdomen as occurred in our 2 cases. If the collection is purulent or generalized peritonitis is present, the abdomen should be explored, drained and stones removed either by laparoscopy or open laparotomy. Reoperation was successful in 2 of our cases. Soper and Dunnegan [20,30] had similar results.
Stones may migrate like sponges or other foreign bodies in the digestive tract [11] as in one of our cases or they can be confused with colonic tumors [2]. Rosin [19] reported stones in a hernia sac. Stones have also been the cause of thoracic empyema [16] and broncopleural fistula with cholelithoptysis [9,15]. The body tries to expel foreign bodies by the port sites or even trought the bowel or other organs.
Persistent infections or sbucutaneous tumors in the port sites, especially in the umbilicus are generally due to retained stones. Fistulography may show the stones.
Complications due to abandoned stones should be included in grade II type of Strasberg classification [5] because no mortality or lasting incapacity was present.
We agree with Welch [27] and other authors [3,8,18] that laparotomy is not routinely indicated when lost stones cannot be retrieved.
Only 25% of them will cause complications. However laparotomy should be considered if a large stone or many stones are lost [23].
Laparotomy should be performed if the gallblader is at large.
Patients should always be informed of stones left in their abdomen, both for legal reasons and for the purpose of early diagnosis of complications.

CONCLUSIONS
Stones which fall into the abdomen during laparoscopic cholecystectomy may lead to severe complications. Every effort should be made to retrieve them. Fever, pain, abdominal abscesses or infected sinus tracts at port sites may be result from lost stones, Fistulography, ultrasonography and CT scans should be performed.
As only 25% of those stones produce complications, laparotomy should not be routinely