• Humans
• Retrospective Studies
• Female
• Male
• Middle Aged
• Reoperation/statistics & numerical data
• Cholecystectomy, Laparoscopic/adverse effects
• Cholecystectomy, Laparoscopic/methods
• Adult
• Postoperative Complications/etiology
• Postoperative Complications/epidemiology
• Gallbladder/surgery
• Aged
• Treatment Outcome
• Operative Time

• subtotal cholecystectomy
• fenestrated cholecystectomy
• endoscopic retrograde cholangiography (erc)

• Humans
• Male
• Female
• Retrospective Studies
• Middle Aged
• Cholecystectomy, Laparoscopic
• Aged
• Cholangiopancreatography, Endoscopic Retrograde/statistics & numerical data
• Length of Stay/statistics & numerical data
• Adult
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Incidence

• UL1 TR002243 NCATS NIH HHS

• Cholecystectomy
• Critical view of safety
• Intraoperative complexity

• Male
• Female
• Humans
• Cholecystectomy, Laparoscopic/adverse effects
• Cholecystectomy, Laparoscopic/methods
• Bile Duct Diseases/etiology
• Surgeons
• Surveys and Questionnaires
• Mexico

• Bail out strategy
• Bile duct injury
• Difficult gallbladder
• Subtotal cholecystectomy

• Bile Ducts/surgery
• Cholecystectomy
• Cholecystectomy, Laparoscopic/adverse effects
• Humans
• Quality of Life
• Retrospective Studies

Objective

Removal of a gallbladder remnant occasionally becomes necessary when retained stones become symptomatic. Although the laparoscopic approach has been described, it is not yet considered the standard of care. We sought to determine the outcomes after completion cholecystectomies in the resource-poor setting within the Caribbean. 

Methods

We carried out an audit of the databases from all hepatobiliary surgeons in the Anglophone Caribbean. We identified all patients who had completion cholecystectomy over the five-year period from July 1, 2012 to June 30, 2018. Retrospective chart review was performed to extract the following data: patient demographics, diagnoses, presenting complaints, operative details, morbidity, mortality, and clinical outcomes. Descriptive statistics were generated using Statistical Packaging for Social Sciences (SPSS), version 12.0 (SPSS Inc., Chicago IL)

Results

There were 12 patients who were subjected to laparoscopic completion cholecystectomy for acute cholecystitis (7), severe biliary pancreatitis (3), and chronic cholecystitis (2) secondary to stones in a gallbladder remnant. There were 10 women and two men at a mean age of 47.4 years (range 32-60; standard deviation (SD) +/-7.81; median 48; mode 52) and a mean body mass index (BMI) of 30.8 Kg/M² (SD +/-3.81; range 26-38; median 29.5). The mean interval between the index operation and the completion operation was 14.8 months (SD +/- 12.3; range 1-48; median 13; mode 18). Five (42%) patients had their original cholecystectomy using the open approach. Five (42%) index operations were done on an emergent basis and the gallbladder remnant was deliberately left behind in three (25%) index operations. The completion cholecystectomies were all completed laparoscopically in 130.5 minutes (SD +/- 30.5; range 90-180, median 125; mode 125) without any conversions or mortality. There were two minor bile leaks that resolved without intervention through an indwelling drain. 

Discussion

Completions cholecystectomy can be completed via the laparoscopic approach with good outcomes and acceptable morbidity and mortality rates. The patients derive the same advantages as elective cholecystectomies. Therefore, the laparoscopic approach, when performed by hepatobiliary surgeons with advanced laparoscopic expertise in specialized centers, should be the new standard of care. 

• caribbean
• cholecystectomy
• completion
• gallbladder
• laparoscopic
• remnant
• stump
• trinidad

We aimed to investigate risk factors related to remnant gallbladder (RGB) stones.

This retrospective study included 73 patients with RGB, in groups with and without RGB calculi. Univariate analyses were used to identify nine variables associated with RGB calculi: sex, age, body mass index (BMI), time to detection, surgical method, length of RGB, angle of RGB and common hepatic duct (CHD), choledocholithiasis, and remnant cholecystitis. Multivariate logistic regression was performed to assess independent predictors of RGB stones. A receiver operating characteristic (ROC) curve was used to estimate model accuracy and determine cut-off values of independent predictors.

We enrolled 73 patients, 33 with and 40 without RGB stones. Univariate analyses showed that age, BMI, time to detection, length of RGB, angle of RGB and CHD were predictors for RGB calculi. Multivariate analyses indicated that time to detection, length of RGB, and angle of RGB and CHD were independent predictors for RGB calculi. The area under the ROC curve of the model was 0.940. Cut-off values of the three indicators were 1.5 years, 2.25 cm, and 22.5°, respectively.

Time to detection, length of RGB, and angle of RGB and CHD were independent predictors of RGB calculi.

• Gallbladder remnant
• calculus
• comparative study
• risk factor
• stone
• time to detection

Patient: Female, 44

Final Diagnosis: Post-cholecystectomy Mirizzi syndrome

Symptoms: Abdominal pain • nausea • vomiting

Medication: Tramadol • hydromorphone • prochlorperazine

Clinical Procedure: US • MRCP • ERCP• choledochoscopy

Specialty: Gastroenterology and Hepatology

Post cholecystectomy syndrome is characterized as recurrence of symptoms as experienced before cholecystectomy. In rare cases, a remnant cystic duct is causing these symptoms and occasionally surgical resection is performed. During surgery, visualization of the biliary ducts could be difficult due to inflammation and dense adhesions.

In this article, we presented a 36-year old woman with post-cholecystectomy syndrome in which we evaluated the feasibility of near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) for visualization of the remnant cystic and common bile duct during robot-assisted surgery. Intraoperative visualization of the remnant biliary duct and other important structures was feasible, and resection of the remnant cystic duct was successfully performed under fluorescence guidance, without any complications.

NIR fluorescence imaging of the biliary ducts using ICG does not prolong the operating time, and could potentially decrease the operation time in difficult procedures, because of easy and fast detection of the biliary tract. Furthermore, it is a non-hazardous and non-invasive technique, as it does not require use of radiation and cannot cause bile duct injury. This case illustrated that ICG NIR fluorescence imaging during difficult robot-assisted surgical procedures of the bile ducts is effective and therefore highly recommended.

The online version of this article (10.1186/s12893-019-0567-8) contains supplementary material, which is available to authorized users.

• Bile duct
• Case report
• Indocyanine green
• Near-infrared fluorescence
• Post cholecystectomy syndrome
• Robot-assisted surgery

• Partial cholecystectomy
• Remnant gallbladder
• Retained gallbladder

• Bile duct injury
• Calot's triangle
• cholecystitis

• Completion cholecystectomy
• Laparoscopic cholecystectomy
• Open cholecystectomy
• Residual gallbladder
• Subtotal cholecystectomy

• Bile duct injury
• Cholecystectomy
• Consensus
• Laparoscopy
• Recommendations

• Cholangiopancreatography, Endoscopic Retrograde
• Cholecystectomy, Laparoscopic/adverse effects
• Cholecystectomy, Laparoscopic/methods
• Cholecystectomy, Laparoscopic/standards
• Consensus
• Female
• Humans
• Male
• Patient Safety
• Postoperative Complications/prevention & control
• Practice Guidelines as Topic/standards
• Preoperative Care/methods
• Risk Assessment
• Safety Management
• Societies, Medical

• Gallstone disease
• Laparoscopy
• Post-cholecystectomy syndrome
• Surgical intervention

Many surgeons opt to perform subtotal cholecystectomy to limit duct injuries in difficult cases. In these cases, however, there is a risk for the gallbladder remnant to become diseased. In these cases, a completion cholecystectomy is necessary.

Although technically challenging, the laparoscopic approach to completion cholecystectomy is feasible and safe, when performed by surgeons with advanced laparoscopic experience.

This report details laparoscopic remnant cholecystectomy and transcystic common duct exploration after previous single-port cholecystectomy.

Recent enthusiasm in the surgical community for less invasive surgical approaches has resulted in widespread application of single-incision techniques. This has been most commonly applied in laparoscopic cholecystectomy in general surgery. Cosmesis appears to be improved, but other advantages remain to be seen. Feasibility has been demonstrated, but there is little description in the current literature regarding complications.

We report the case of a patient who previously underwent single-incision laparoscopic cholecystectomy for symptomatic gallstone disease. After a brief symptom-free interval, she developed acute pancreatitis. At evaluation, imaging results of ultrasonography and magnetic resonance cholangiopancreatography demonstrated a retained gallbladder with cholelithiasis. The patient was subsequently referred to our hospital, where she underwent further evaluation and surgical intervention.

Our patient underwent 4-port laparoscopic remnant cholecystectomy with transcystic common bile duct exploration. Operative exploration demonstrated a large remnant gallbladder and a partially obstructed cystic duct with many stones. Transcystic exploration with balloon extraction resulted in duct clearance. The procedure took 75 minutes, with minimal blood loss. The patient's postoperative course was uneventful. Final pathology results demonstrated a remnant gallbladder with cholelithiasis and cholecystitis.

This report is the first in the literature to describe successful laparoscopic remnant cholecystectomy and transcystic common bile duct exploration after previous single-port cholecystectomy. Although inadvertent partial cholecystectomy is not unique to this technique, single-port laparoscopic procedures may result in different and significant complications.