The sequelae of spilled gallstones after Laparoscopic cholecystectomy (LC) and the occurring complications may go unnoticed for a long time and can be a diagnostic challenge. The aim of this survey was to study the knowledge, attitude, and practices of surgeons regarding spilled gallstones during LC. An observational, cross-sectional survey, using a questionnaire based on 11 self-answered close-ended questions, was conducted among general surgeons. Of the 138 respondents only 29.7% had observed a complication related to gallstone spillage during LC. There was varied opinion of surgeons regarding management of spilled gallstones, documenting the same in operative notes and consent. It was observed that there is lack of knowledge regarding the complications related to gallstone spillage during LC. There is need to educate surgeons regarding safe practices during LC to avoid gallstone spillage, early diagnosis, and management of complications. There is need to standardize practice to retrieve lost gallstones to reduce complication and legal consequences.
Laparoscopic cholecystectomy is now the method of choice to treat symptomatic gallstones due to lower associated postoperative morbidity. However, it comes with its own spectrum of complications, the two most unique ones being injury to the biliary tract and spillage of gallstones. The former can be minimized by practice and exercising due care during dissection. The latter, however, presents with consequences after a rather protracted period of time, as a whole range of seemingly unrelated symptoms which take the patient to a GP rather than implicate the laparoscopic surgeon.
The aim of this survey was to study the knowledge, attitude, and practices of residents and staff working in the department of surgery in various hospitals of South India with regard to spilled gallstones during laparoscopic cholecystectomy.
This was a cross-sectional study carried out in the month of November, 2013, during a surgical conference which saw surgical residents and staff from several teaching institutes of Karnataka, Tamil Nadu, and Kerala. The questionnaire contained 11 self-answered, close-ended questions which addressed the responder’s experience with and knowledge of complications due to lost gallstones, practices regarding patient information and documentation, legal liability of the operating surgeon.
Of the 138 respondents, 22 (15.9%) were consultants while 116 (84.1%) were residents pursuing their postgraduation in general surgery (Table
Response to questionnaire on gallstone spillage during LC.
Question | Number | Percentage |
---|---|---|
Designation | ||
Consultant | 22 | 15.9 |
Resident | 116 | 84.1 |
Incidence | ||
0–10% | 85 | 61.6 |
11–25% | 37 | 26.8 |
26–40% | 11 | 8.0 |
>40% | 5 | 3.6 |
Complication seen | ||
Yes | 41 | 29.7 |
No | 97 | 70.3 |
Should gallstone spillage be included in informed consent? | ||
Yes | 100 | 72.5 |
No | 38 | 27.5 |
Gallstone spillage included in informed consent | ||
Yes | 67 | 48.6 |
No | 71 | 51.4 |
Intervention for gallstone spillage | ||
Convert to open for retrieval | 12 | 8.7 |
Laparoscopic retrieval | 94 | 68.1 |
Peritoneal wash and suction | 28 | 20.3 |
None | 4 | 2.9 |
Necessary to document gallstone spillage in operative notes | ||
Yes | 110 | 79.7 |
No | 28 | 20.3 |
Document gallstone spillage in operative notes | ||
Yes | 97 | 70.3 |
No | 41 | 29.7 |
Duration of follow-up for gallstone spillage | ||
2 years | 106 | 76.8 |
5 years | 21 | 15.2 |
10 years | 10 | 7.2 |
20 years | 1 | 0.7 |
Number of complications identified | ||
<5 | 114 | 82.6 |
>5 | 24 | 17.4 |
Can operating surgeon be held legally liable for complication following gallstone spillage? | ||
Yes | 33 | 23.9 |
No | 105 | 76.1 |
The experience of this cohort with complications associated with gallstone spillage during laparoscopic cholecystectomy was only 29.7%. With regard to the incidence of spillage, the majority (61.6%) opined that it was less than 10%. When asked about the duration of follow-up, the majority (76.8%) thought 2 years was sufficiently long (Table
The questionnaire presented a list of 20 possible complications of which the respondents had to pick the ones which could be directly attributed to spilled gallstones. The complications and the responses are presented in Figure
“Which of the following can be complications following gallstones spillage?”
In case of lost gallstones, 88.4% of the respondents would not convert to an open procedure and would attempt to retrieve the stones laparoscopically (68.1%) or give thorough peritoneal wash and suction (20.3%). 8.7% would convert to an open cholecystectomy whereas 2.9% would rather not do anything.
72.5% of the respondents thought it was necessary to include the risk of spillage and associated complications in preoperative consent but only 48.6% actually did so. 79.7% considered it necessary to mention the lost gallstones in operative notes and 70.3% actually documented the same.
Only 24% of the respondents had the opinion that the operating surgeon should be held legally responsible for the complications associated with the spilled gallstones.
Laparoscopic cholecystectomy is the gold standard for treating symptomatic gallstones. Perforation of the gallbladder occurs frequently during laparoscopic cholecystectomy and is reported in the range of 10%–40% [
Complications that result from these spilled stones are between 0.08% and 0.3% [
In our survey majority of participants (70%) did not come across the complications associated with spilled gallstones. Those complications are multiple and widespread; they include abdominal wall abscess [
The time interval between the surgery and the complications of spilled stones varies from as short as one month to as long as 20 years [
The significant risk factors for these complications are acute cholecystitis, spillage of pigmented stones, perihepatic localization of spilled stones, multiple stones (>15) or size (>1.5 cm), and old age [
In our study 72% of participants believed that spillage of gallstone during surgery should be included in informed consent but only 48% were practicing the same. The clear documentation of the intraoperative gallstone spillage in the medical report is recommended for alerting the clinician in the future to the possibility of stones causing any subsequent problems that might lead to earlier diagnosis. In our study around 80% of participants agreed that stone spillage should be mentioned in the operative notes and 70% were practicing the same.
Only a high index of clinical suspicion may lead to correct identification. Ultrasound, computed tomography, and magnetic resonance imaging (MRI) are valuable as diagnostic tools. Ultrasound may identify radiolucent biliary stones in the middle of the inflammatory mass by detecting the hyperechoic acoustic signals from these stones. Ultrasound is more sensitive in detecting stones in abscesses compared with MRI [
The prevention of complications is by preventing the stone spillage by careful dissection and use of retrieval bag before extraction of the gallbladder through the port. If gallbladder perforation occurs, the use of suction devices to minimize the spilled bile and spilled gallstones as well as the use of an endobag is mandatory. If possible, the hole in the gallbladder should be closed by the grasp forceps or by an endoclip or endoloop.
Once spillage of stone occurs then every attempt should be made to retrieve all the spilled stones laparoscopically and by performing thorough peritoneal wash with aspiration. Intense irrigation and suction should be performed after collecting the visible stones in order to minimize the number of lost gallstones. This should be done carefully without spreading the gallstones into difficult accessible sites. Stone collection might be facilitated by the use of an intra-abdominal bag and a laparoscopic grasper, a 10 mm suction device, or a “shuttle” stone collector [
The treatment of the complication consists of eradication of source of infection. Stones which are the foci of infection in these abscesses and sinuses should be completely removed for cure [
Smaller stones usually less than 1 cm can often be removed through the nephroscope and using a basket. Larger ones need fragmentation by mechanical means or lithotripsy before attempting removal.
In dealing with a deep seated abscess with a tortuous tract electrohydraulic lithotripsy in association with choledochoscopy is a good alternative [
Gallstones causing vesical granulomas resulting in haematuria have been dealt with by cystoscopic excision of the granulomas [
There is a dearth of knowledge regarding the consequences and modes of presentation of complication related to lost gallstone. There are varied practices with regard to management, documentation, and patient information. There is need to educate surgeons regarding safe practices during LC to avoid gallstone spillage, early diagnosis, and management of complications. There is need to standardize practice to retrieve lost gallstones to reduce complication and legal consequences.
The authors declare that there is no conflict of interests regarding the publication of this paper.