Laparoscopic Management of Biliary Stone Disease

Management of Acceptable Complications

Intra-operative Bile Spillage

Most laparoscopic cholecystectomies will generate some form of bile spillage. As a rule, we thoroughly irrigate the intra-abdominal cavity at the end of each case with at least two liters of normal saline which effectively removes this spillage. In the case of purulent cholecystitis, a Blake drain is routinely left in the intra-abdominal cavity.

Dropped Gallstones

For years we believed leaving gallstones in the intra-abdominal cavity should not create any future problems. However, the literature reports the increase of infectious complications secondary to gallstones left in the intra-abdominal cavity. For this reason, our guidelines mandate the removal of all possible intra-abdominal gallstones during these procedures.

Post-operative Bile Leaks

Postoperative bile leaks are rare but do occur. The patient usually presents 24 to 72 hours after the laparoscopic cholecystectomy complaining of severe abdominal pain, most intense in the right upper quadrant. The white blood cell count is usually elevated. The best diagnostic modality to demonstrate this bile leak is a Pipida (P-isopropylacetanilide-iminodiacetic acid) Scintigram (99% accuracy). These leaks are best managed by the placement of a common bile duct stent via ERC. The patient will respond almost immediately to such treatment. The stent is left in place for four to six weeks. Lastly, we have noted bile leaks will occur post-laparoscopic cholecystectomy with an unsuspected, retained common bile duct stone. The increased pressure in the common bile duct will re-open secondary bile ducts in the gallbladder bed, thus generating a bile leak.

Postoperative Persistent RUQ ( Right Upper Quadrant) Pain

Numerous patients (11%) will complain of an intermittent sharp pain in the RUQ not related to meals or any other activities. The patient's liver function tests should be checked to identify a potential retained common bile duct stone. A Complete Blood Count should also obtained. If the serum studies are within normal limits, and the pain is not impairing their life style or recovery, the patient is observed. Although the exact etiology of this pain has never been identified, we feel it emanates from the lateral trocar sites. Nonetheless, these patients improved, and their symptoms disappeared within ten days.

Postoperative Diarrhea

Significant postoperative diarrhea has been reported in 1.2 % of the patients. We routinely do not initiate any treatment in the early postoperative period. If the diarrhea persists beyond the third postoperative week, the patient is given Lomotil®. The majority of these patients improved on this regimen alone. It was necessary for 0.1% of the patients to undergo further therapeutic intervention such as oral cholestyramine, etc.