Correspondence Address:
P T Connolly, Department of General Surgery, Hope Hospital, Stott Lane, Salford, M6 8HD Email: PTFconn@aol.com.

ABSTRACT

A fifty four year old insulin dependent diabetic presented with a recurrent
abscess on the right side of the lower back. A painful swelling had appeared
intermittently for eighteen months and previously required incision and drainage.
At repeat operation a pea sized multifaceted gallstone was discovered at the base of
the cavity. We postulate that a gallstone was spilled into the peritoneal cavity during
a laparoscopic cholecystectomy performed three years earlier. Over time this stone
produced a peritoneal cutaneous fistulae resulting in a recurrent cutaneous abscess.
This case is an example of a rare and delayed complication of laparoscopic
cholecystectomy which focuses attention towards a variety of unusual clinical
presentations of retained gallstones.

CASE REPORT

A fifty four year old insulin dependent diabetic presented with a large abscess on
the right side of her lower back, approximately 5cms superior to the posterior
superior iliac spine. Over the previous 18 months the patient had on occasion
experienced a painful swelling in this area. Six months earlier an incision and
drainage of a simple abscess in the same area had been performed.
There was no record of the presence of a sebaceous cyst being responsible for the
abscess in the operation note. The recurrence of this unusual abscess raised the
possibility of a peritoneal cutaneous fistula. On direct questioning the patient denied
any symptoms suggestive of colonic disease or episodes of abdominal pain. An
abdominal CT scan was arranged to exclude intra peritoneal involvement prior to
incision and drainage of the abscess. The scan revealed evidence of inflammation of
the soft tissues around the abscess but no evidence of any intra-abdominal
abnormality was detected. Three years previously the patient had undergone an
uneventful laparoscopic cholecystectomy for recurrent cholecystitis. The abscess
cavity was opened and a large volume of pus was evacuated, at the base of the cavity
a multifaceted pea sized gallstone was discovered. After careful evaluation there was
no evidence of a communication with the peritoneal cavity. The cavity was packed
with an antiseptic soaked ribbon gauze. The patient was discharged after having the
pack changed the following day and continued to make an uneventful recovery.

DISCUSSION

Over the last 10 years laparoscopic cholecystectomy has become a routine operation
with 40,000 performed annually in the U.K. Specific late complications are now
being encountered that were not associated with open cholecystectomies.
Detection of a gallstone in a cutaneous abscess cavity caused great surprise. The
mechanism by which the gallstone reached this location is uncertain. It is likely that a
stone spilled during the laparoscopic cholecystectomy resulted in the development of
an intra-abdominal abscess, which eroded into the posterior abdominal wall.
Continued migration of the stone eventually produced a peritoneal-cutaneous fistula
resulting in the cutaneous abscess. An alternative mechanism would be that during
extraction of an instrument or even the gallbladder, that a spilled stone became
embedded in the port site. This is disputed as the stone was located a considerable
distance inferiorly and lateral to the closest port site, which would be the natural site
for a cutaneous abscess. On review of the operation note of the laparoscopic
cholecystectomy no record had been made whether the gallbladder perforated and
stones were spilled. It is apparent from the operation note that a bag was not used to
retrieve the gallbladder from the peritoneal cavity. The use of a bag may reduce the
possibility of stones being shed into the abdominal cavity during extraction of a large
gallbladder through a narrow port. Stones are spilled in as many as 40% of
laparoscopic cholecystectomies (1). Between 10 -15 % of unretrieved gallstones result
in complications. (2) A number of predictable complications such as intra abdominal
abscesses, retroperitoneal abscesses, intra hepatic abscesses and subphrenic abscesses
may occur. (3)

Intra-peritoneal stones are also responsible for other unusual complications such as
colo-cutaneous fistulas (4), pulmonary abscesses (5) and even passage of gallstones
per urethra (6).Gallstones have been discovered in sputum samples after violent
expectoration as part of a phenomenon known as cholelithoptysis (7). Some of the
unusual complications caused by retained intra abdominal gallstones have delayed
presentations and present with symptoms which are not typical of biliary disease often
resulting in a delay in diagnosis (8).

Percutaneous drainage of intraperitoneal abscess cavities and removal of stones has
been achieved (9). Both laparotomies and thoracotomies with lung decortication
have been cited in the literature as the treatment of intra abdominal and intra thoracic
abscess formation due to retained stones.

The key message of this case report is to focus the clinician’s attention to the
possibility of spilled intra-abdominal stones being the source for some unusual
clinical presentations in patients who had previously undergone laparoscopic
cholecystectomy. Investigation of retained stones includes ultrasound and CT
scanning. Removal of Gallstones causing such complications must be achieved
before eradication of the infection is possible (10).

CONCLUSION
After review of the literature we recommend that if stones are spilled into the
peritoneal cavity at the time of surgery, then strenuous efforts should be made to
retrieve these stones. As part of each operation note a record should be made of the
presence or absence of any spilled or retained stones. Documentation of spilled
stones is of great assistance in the diagnosis of future complications. We recommend
that the use of an endoscopic retrieval bag to extract the gallbladder become adopted
by all surgeons as this is likely to reduce the number of spilled stones. The patient
should be informed of any spilled stones after the operation and advised that a small
percentage of patients will develop unusual complications that require further
treatment. This information should be relayed to medical staff if future episodes of
abdominal pain or other unusual symptoms develop.

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