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Case Reports in Surgery
Volume 2012, Article ID 573092, 3 pages
RetroperitonealAbscessFormationas a Result of
George Papadakis,Konstantinos Atmatzidis,andJohn Makris
2nd Surgical Department, School of Medicine, “G. Gennimatas” General Hospital, Aristotle University of Thessaloniki,
54635 Thessaloniki, Greece
Correspondence should be addressed to Grigoris Chatzimavroudis, firstname.lastname@example.org
Received 17 October 2012; Accepted 8 November 2012
Academic Editors: T. Hotta, S.-i. Kosugi, and K. Reavis
Copyright © 2012 Grigoris Chatzimavroudis et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
One of the complications of laparoscopic cholecystectomy for gallstone disease that seems to exceed that of the traditional open
method is the gallbladder perforation and gallstone spillage. Its incidence can occur in up to 40% of patients, and in most cases its
course is uneventful. However in few cases an abdominal abscess can develop, which may lead to significant morbidity. Rarely an
abscess formation due to spilled and lost gallstones may occur in the retroperitoneal space. We herein report the case of a female
patientwhopresentedwithclinical symptomsofsepsissixmonthsfollowinglaparoscopic cholecystectomy. Imaginginvestigations
revealed the presence of a retroperitoneal abscess due to retained gallstones. Due to patient’s decision to refuse abscess’s surgical
drainage, she underwent CT-guided drainage. The 24-month followup of the patient has been uneventful, and the patient remains
in good general condition.
Laparoscopic cholecystectomy (LC) has been established as
the gold standard method for the treatment of gallstone dis-
ease due to its advantages, including less postoperative pain,
shortened hospitalization, faster recovery, and improved
cosmesis. However, LC is not without complications; in fact,
specific complications can occur with higher frequency in
LC than in traditional open approach, and gallbladder per-
foration with subsequent bile and gallstone spillage is
included among them. Though common in incidence, rang-
ing from 8% to 40% , the clinical importance of gallblad-
der perforation and gallstone spillage still remains unclear.
Abscess formation due to lost gallstones occurs rarely and
predominantly develops intraperitoneally . We report the
case of a patient with retroperitoneal abscess formation six
months following LC.
A 72-year-old woman underwent LC due to symptomatic
gallstone disease. Her past medical history was uneventful.
Intraoperatively, the gallbladder was perforated resulting in
bile and gallstone spillage into the peritoneal cavity. The
abdominal cavity was irrigated with 1lt of normal saline to
dilute and aspirate bile and gallstones; however the retrieval
of the spilled gallstones was incomplete as a combined result
of their large number and small size. The postoperative
course of the patient was uneventful.
Six months postoperatively, the patient presented to our
department complaining of high fever (body temperature
up to 39.2◦C), chills, and constant pain in the right lumbar
region for two days. On clinical examination the right hypo-
chondrium and right lumbar region were both tender. Blood
tests revealed white blood cell count 13.200/mL, neutrophils
2 Case Reports in Surgery
Figure 1: Ultrasound examination showing the presence of a
retroperitoneal abscess with hyperechoic foci (spilled gallstones)
87.3%, and C-reactive protein 14.9mg/dL (normal value
The patient underwent ultrasound examination which
revealed an abscess cavity in the right retroperitoneal space,
containing multiple hyperechoic foci (Figure 1). Due to the
recent history of LC complicated with spilled gallstones, the
diagnosis of a retroperitoneal abscess was suspected, which
was confirmed by the computed tomography (CT) scan
findings (Figure 2).
The patient was recommended to undergo surgical
drainage of the abscess, but she refused. Alternatively, she
underwent percutaneous CT-guided drainage of the abscess.
analysis which grew Klebsiella pneumoniae. The patient was
given intravenous antibiotics (ciprofloxacin 400mg ×2 and
metronidazole 500mg ×3) for seven days, and afterwards
an intensive follow-up program. Twenty-four months after
abscess drainage, the patient has remained asymptomatic.
Based on the statistics, a complication that almost every
laparoscopic surgeon willfaceat leastone time in his surgical
career is gallbladder perforation with subsequent bile and
is one of the most common surgical operations, combined
by the high incidence (up to 40%) of gallbladder perforation
in the vast majority of cases with spilled gallstones, the
postoperative course of patients is unremarkable. Reviewing
1000LCs . Similarly, in a more recent article representing
a single center experience, Tummer et al. reported that only
seven out of 1528 (0.45%) patients with LC presented with
complications due to retained gallstones .
Figure 2: CT scan showing a retroperitoneal abscess (arrow) due to
Zehetner et al. reviewed all the reported complications
from lost gallstones and found that abscesses in the abdom-
inal wall and intra-abdominal abscesses were the most fre-
quently reported complications . In 2002 Papasavas et al.
reviewed 127 cases of spilled gallstones presenting with
various clinical manifestations. Of these cases, more than
toneal plus abdominal wall abscesses), while 10% suffered
from retroperitoneal abscess . Since 2002 only five new
cases of retroperitoneal abscess due to retained gallstones
have been reported [7–11].
Other than abscess formation complications due to
spilled gallstones include fistula formation, intestinal ob-
struction, pleural empyema, and broncholithiasis .
It remains unclear and a matter of controversy whether
gallbladder perforation with bile and stone spillage during
LC should be an indication for conversion to laparotomy.
According to Brockmann et al., risk factors for complications
after gallstone spillage are old age, stone size >15mm,
number of spilled stones >15, pigment stones, and infected
bile . However even for these cases the majority of authors
do not advice conversion to open surgery [2, 4, 5, 11].
Instead, it is widely recommended to remove as many of the
spilled stones as possible by laparoscopic means (e.g., grasp-
ers, 10mm suction device) and intensively irrigate the peri-
toneal cavity. Moreover we believe that it is of highest
importance to clearly document the incidence of gallstone
spillage in the medical report and inform the patient in order
to early recognize signs of any possible complication.
It is almost universally accepted that treatment of an
abscess due to lost gallstones should include not only abscess
drainage and antibiotic administration but also removal
of the lost gallstones, otherwise the abscess might recur.
Though we strongly agree with this approach, our patient’s
treatment did not include gallstone removal because she
denied any surgical intervention. Two years after percuta-
neous drainage of the abscess, she has remained asympto-
matic but still on close followup.
In conclusion, our reported case shows that, though
rarely, spilled gallstones during LC can lead to severe morbi-
dity and emphasizes the importance of having high index of
Case Reports in Surgery3 Download full-text
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