Introduction

Cholecystectomy is the most commonly performed general surgical operation worldwide (1). Laparoscopic cholecystectomy (LC) is the gold standard treatment of gallstones today. The most frequent complications are gallbladder perforation, gallstone spillage and bile duct injuries (2). The incidence of gallbladder perforation and split gallstones were 18.3% and 7.3% respectively in a review by australian group which included around 18,000 laparoscopic cholecystectomies. They reported that around one third of split gallstones were left unretrieved (3).

Patients may present with intraperitoneal or abdominal wall abscess secondary to retained gallstones after uncomplicated LC at any time and it accounts for approximately 14% of the complications from retained gallstones and majority were along the port sites (4-6). There are many studies attributing the abdominal wall abscess post LC to retained gallstones or bile spillage but the occurrence of an abdominal wall abscess without these underlying causes is rare.

We report one such case of an abdominal wall abscess presenting one year after LC and describe laparoscopic drainage as our choice of management for chronic abscess post LC.

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Case Report

An 81-year-old male presented with complaints of loss of weight and appetite for 3 months. There were no associated symptoms like fever or nausea or vomiting or bowel and bladder disturbances. Past medical history was noncontributory other than his only previous surgery. He had undergone an uncomplicated LC for symptomatic cholelithiasis one year previously. There was no spillage of bile or gall stones at surgery as reported in the previous operation report. His postoperative course was uneventful. On general physical examination, the patient was afebrile with a soft, nondistended and nontender abdomen. Port sites were normal. There were no signs of inflammation like fullness, erythema or tenderness. No palpable lumps were felt anywhere in the abdomen. There was no clinical evidence of any abscess or infection at port sites.

Routine bloods were within normal limits. Ultrasound abdomen showed multiple ill-defined lesions of size 2-6cm in the liver and also a mass of 6x2.5cm is seen in the right lobe of liver raising the suspicion of a neoplastic lesion. CT abdomen and pelvis showed thickening of right perihepatic peritoneum measuring 15x15x3.5 cm which was indenting the right lobe hepatic convexity associated with perihepatic fluid collection, suggestive of a Chronic granulomatous state or Atypical mesothelioma (Fig. 1).

Click to view Figure 1

There were no space occupying lesions in the liver as was reported in the Ultrasound examination. An Upper GI Endoscopy and Colonoscopy showed normal mucosal study.

Diagnostic laparoscopy was performed. It showed bulge in the abdominal wall in the right hypochondrium. There were no granulomatous lesions anywhere intra peritoneally. The bulge was explored and it was found to be an abscess cavity. The cavity was deroofed and around 30ml of frank pus drained. The cavity was washed out. Intraoperative pictures at different stages of the surgery is shown in Fig. 2.

Click to view Figure 2

Gram stain of pus showed plenty of pus cells and no organisms. Culture at the end of 48 hours yields no growth of any organism. Histopathology showed fibrofatty tissue with few muscle bundles. Dense collections of acute inflammatory cell collection present in this tissue. Final impression was consistent with abscess. He was on antibiotics for 5 days. The follow up was uneventful. He remained well with a return of normal appetite in 2 weeks. He remained asymptomatic at the 15-month followup. As he was asymptomatic, no further investigations were done.

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Discussion

The gold standard treatment of gallstones is LC due to its known advantages. However, this procedure also brings some risks like gallbladder perforation with bile spillage, gallstone spillage and bile duct injuries. Patients may present with complications like intra or extra abdominal abscesses due to bile spillage or retained gallstones at any time following surgery.

If we look at the causes for retained gallstones and bile spillage, Nooghabi et al (7) in a review article noted that increased incidence was seen when surgery was performed for an acutely inflammed gallbladdder, in the elderly, in obese patients, in males and also in the presence of adhesions. In order to prevent bile spillage, careful dissection and identification of the correct planes should be done during removal of gallbladder from the liver bed. Decompression can be done in case of distended gallbladder. Gallstones and bile spillage can occur at the time of specimen retrieval also and the best way to avoid this is to use an endobag. This prevents port site contamination and retention of gallstones in the port sites. If at all any spillage occurs at the time of dissection or specimen retrieval, the surgeon should ensure removal of all visible stones and use copious saline irrigation to flush the port site (8).

However, in our case we didn’t find any gallstone in the abscess cavity. Majority of intra or extra abdominal abscess were caused by spilt gallstones in primary surgery but in our case, there was no bile spillage or retained gallstones. The cause for the abscess in our case remains an enigma. We can only guess that this may be (a) a port site infection tracking obliquely towards the peritoneum or (b) an unrelated abscess in the abdominal wall due to seeding from a bacteraemia.

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Conclusion

Despite the majority of patients remaining asymptomatic, intra or extra abdominal abscess can occur at any time post laparoscopic cholecystectomy. Thorough investigation and timely intervention, including a laparoscopic approach is the key to management.

Compliance with Ethical Standards

We have the patient’s permission to report this case.

Conflict of Interest   

The authors declare that they have no conflict of interest.

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References

1. Fingar KR, Stocks C, Weiss AJ, et al. Most Frequent Operating Room Procedures Performed in US Hospitals, 2003–2012 Statistical Brief# 186.

2. Mahabaleshwar V, Kaman L, Iqbal J, et al. Monopolar electrocautery versus ultrasonic dissection of the gallbladder from the gallbladder bed in laparoscopic cholecystectomy: a randomized controlled trial. Canadian journal of surgery. 2012;55(5):307.

3. Woodfield JC, Rodgers M, Windsor JA. Peritoneal gallstones following laparoscopic cholecystectomy. Surgical Endoscopy and Other Interventional Techniques. 2004;18(8):1200-7.

4. Grass F, Fournier I, Bettschart V. Abdominal wall abscess after cholecystectomy. BMC research notes. 2015;8(1):334.

5. Christensen AM, Christensen MM. Abdominal wall abscess containing gallstones as a late complication to laparoscopic cholecystectomy performed 17 years earlier. Journal of surgical case reports. 2013;2013(1).

6. Dobradin A, Jugmohan S, Dabul L. Gallstone-related abdominal abscess 8 years after laparoscopic cholecystectomy. JSLS: Journal of the Society of Laparoendoscopic Surgeons. 2013;17(1):139.

7. Nooghabi AJ, Hassanpour M, Jangjoo A. Consequences of lost gallstones during laparoscopic cholecystectomy: a review article. Surgical Laparoscopy Endoscopy & Percutaneous Techniques. 2016 ;26(3):183-92.

8. Heywood S, Wagstaff B, Tait N. An unusual site of gallstones five years after laparoscopic cholecystectomy. International journal of surgery case reports. 2019; 56:107-9.