Abdominal abscess due to retained gallstones 5 years after laparoscopic cholecystectomy

Background

This report describes a rare but significant complication of laparoscopic cholecystectomy (LC). Gallstones are extremely common and LC is one of the most common surgical procedures. It is not uncommon for gallstones to be spilled and there is a general acceptance that this event is of little clinical significance. It is very important to try and avoid such contamination during LC. Should such an eventuality occur, retrieval of the spilled stones should be meticulous and the event recorded in the operation notes. One should be vigilant and cognisant of potential complications when stones are spilled.

Case presentation

A 76-year-old woman with non-insulin dependent diabetes presented with a 2 week history of fever, rigors, night sweats and an increasingly painful right sided loin mass. On examination she was pyrexic (37.8°C) with a large brawny fluctuant swelling in the right loin suggestive of an abscess.

A smaller abscess had been drained radiologically from the same site 1 year previously. At that time investigations including colonoscopy, oesophagogastroduodenoscopy (OGD) and renal ultrasonography failed to identify the source. Relevant past medical history included type II diabetes mellitus, osteoarthritis necessitating a total right hip replacement 20 years previously, and an elective LC 5 years previously.

Investigations

Bloods: Haemoglobin 10.5 mg/dl, white blood cell count 17.9x10⁹ /ml, neutrophilia 15.7x10⁹ /ml, C reactive protein 240 mg/dl.

Computed tomography (CT) scan: Huge right flank abscess (17x10 cm) with air fluid collection in the right retro-peritoneal space extending through the muscles of the lateral abdominal wall into the soft tissues in the region of the Grynfeltt's triangle ( fig 1 ). No obvious aetiology was identifiable.

Differential diagnosis

Renal or gastrointestinal sepsis would be most commonly culpable for this presentation-that is, appendicitis, solitary caecal diverticulitis, diverticular disease, perforated caecal tumour or perinephric abscess secondary to pyelonephritis. One should also be cognisant of opportunistic infection in susceptible patients, such as fungal infection and tuberculosis.

Treatment

Incision and drainage of the abscess in the left lateral position under general anaesthesia was undertaken. A total of 550 ml of frank, foul smelling pus was drained, and...