REVIEW ARTICLE
Retained Abdominal Gallstones After Laparoscopic
Cholecystectomy: A Systematic Review
Baha T. Demirbas, MD, Bahadir M. Gulluoglu, MD, and A. Ozdemir Aktan, MD
Aim: The aim of this study is to make a systematic review of high-
quality published trails regarding the complications of retained
gallstones after laparoscopic cholecystectomy for cholelitiasis.
Materials and Methods: Medline search from 1987 to 2013 was
done. Nine studies with >500 LCs which reported retained gall-
stones and perforated gallbladders were analyzed systematically.
Results: Of 536 listed reports including case reports, clinical trials,
reviews, journal articles, and meta-analytic reports; 9 studies each
reporting >500 LCs which reported the incidence of perforated
gallbladders and spilled stones were found. The number of oper-
ations, the number of perforated gallbladders, the number of
patients who had gallstone spillage, and the postoperative com-
plications were searched in these studies and the strongest and
weakest aspects of the articles were discussed.
Conclusions: Retained abdominal gallstones can cause various
postoperative problems including extra-abdominal complications.
In case of perforation of the gallbladder during laparoscopic
cholecystectomy, spilled gallstones should be collected to prevent
further complications but conversion to open surgery is not
mandatory.
Key Words: laparoscopic cholecystectomy, gallbladder perforation,
retained gallstones
(Surg Laparosc Endosc Percutan Tech 2015;25:9799)
L aparoscopic cholecystectomy (LC) is the treatment of
choice for symptomatic cholelitiasis. The incidence of
gallbladder perforation and spillage of gallstones during
LC varies between 6% and 40%.1,2 As retained gallstones
can cause a wide range of complications after surgery,
either conversion to open surgery or just retrieving the
stones as much as possible with irrigation of the abdomen
has been a matter of debate.
The purpose of this review is to evaluate the compli-
cations through a systematic literature investigation to
delineate the variety and seriousness of complications and
indicate the frequency and management of spilled and
retained gallstones after LC.
MATERIALS AND METHODS
We searched the relevant database to extract quantitative
data from the articles but as the outcomes were heterogenous,
we analyzed the individual studies qualitatively as a systematic
Received for publication April 7, 2014; accepted September 1, 2014.
From the Department of General Surgery, Marmara University Pendik
Hospital, Istanbul, Turkey.
The authors declare no conicts of interest.
Reprints: Baha T. Demirbas, MD, Department of General Surgery,
Marmara University Pendik Hospital, 1.oor Fevzi Cakmak mh.
Mimar Sinan Cd. PC:34896 No:41 Ust Kaynarca, Pendik, Istanbul,
Turkey (e-mail: tolgademirbas@yahoo.com).
Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.
Surg Laparosc Endosc Percutan Tech  Volume 25, Number 2, April 2015
review. A thorough review was done in the NCBI National
Library of Medicine (Pub Med; January 1987 to October 2013)
by 2 authors. LCs which reported retained gallstones and
perforated gallbladders were analyzed systematically.
The search was done by using the following words:
gallbladder perforation, spilled gallstones, LC, retained
gallstones, abscess, stula, lost gallstones.
The eligibility of the studies was the inclusion of the
key words in the title or abstract. The data were obtained
from the studies independently. The results of the studies
were summarized, duplications were eliminated. Only arti-
cles written in English were included in the study. The
number of operations, the number of perforated gall-
bladders, the incidence of gallstone spillage and retained
stones, follow-up period, and the postoperative complica-
tions were extracted from the articles.
Each selected article was evaluated according to
STROBE statement: checklist of items that should be
included in reports of cohort studies.3
RESULTS
Of 376 listed reports including case reports, clinical
trials, reviews, and meta-analytic reports; there were 193
case reports, 138 clinical trials, 41 reviews, and 4 meta-
analyses.
Totally 9 studies412 each reporting >500 LCs which
reported the incidence of retained peritoneal gallstones and/
or perforated gallbladders were included in this review
(Table 1). Studies reporting complication rates were also
included in the review.
Two studies did not report the follow-up period.8,9 In
2 studies, although the incidence of perforations or retained
stones were not given, the complication rates were
reported.10,11 In 3 studies perforation rates were reported
but the incidence of retained gallstones was not given.4,5,8
There were 3 studies which reported all required data
including the number of cases, follow-up period, compli-
cation rates, and incidences of gallbladder perforation and
retained gallstones during LC.6,7,12
DISCUSSION
The aim of this review is to investigate the incidence
and results of gallstone spillage during LC in the literature
through a systematic review.
Perforation of the gallbladder and gallstone spillage
occurs frequently in 6% to 40% of cases during LC.1,24 Per-
forations mostly occur during the dissection of the gallbladder
from the liver bed and during the extraction of the gallbladder
from the trochar site. The incidence of gallbladder perforation
rises with inammation as such gallbladders are fragile and
prone to rupture under the force of traction.13 However, some
authors have not observed acute cholecystitis as an independ-
ent risk factor for perforation.4
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Demirbas et al Surg Laparosc Endosc Percutan Tech
TABLE 1. Number of Cases, Mean Follow-up, and the Incidences of Gallbladder Perforation, Retained Gallstones, and Complication
Rates in Selected Studies
References LCs (n) Perforation (%) Mean follow-up (mo)
Schafer etal4 10174 5.7
Rice et al5 1059 29
Sarli et al6 1127 11.6
Memon et al7 856 16
Hui et al8 1412 36
Diez et al9 3686 17
Hawasli et al10 5526
Horton and Florence11 1130
Manukyan et al12 580 17
LC indicates laparoscopic cholecystectomy.
Despite the reality that the incidence of both imme-
diate and late complications is low after spillage of gall-
stones after LC,2 serious complications occurring as a result
of lost stones have been reported in the literature.
Schafer et al4 reported a population of 10,174 LCs
with 581 intraoperative gallstone spillage (5.7%). A total of
547 of these operations were nished laparoscopically,
whereas in 34 cases the operation was converted to an open
procedure during which all the spilled gallstones were
removed. The authors reported 8 patients who had serious
complications due to retained intra-abdominal stones and
concluded that every attempt to retrieve the spilt gallstones
should be performed. Authors conclude that spillage of
gallstones to the abdomen is a common problem, but
serious postoperative complications are very rare (0.08%).
The follow-up period of the patients was 16 to 56 months
and the exact number of lost gallstones was not evaluated.
This report revealed a high risk of intra-abdominal abscess
formation in the elderly patients with acute cholecystitis
and perforation of the gallbladder. The data were analyzed
retrospectively in this article and the characteristics of the
study participants were not clearly indicated.
Rice et al5 analyzed 1059 patients and found iatrogenic
perforations in 306 patients (29%). In 115 patients spillage of
bile and gallstones were detected. The variables associated with
the perforation were male sex, increasing age, body weight, and
the presence of omental adhesions. This study revealed that
gallbladder perforation could lead to signicant complications
(abdominal and thoracal abscesses) which occurred in 7 of their
cases and therefore retrieval of as many gallstones as possible
was recommended in the presence of perforation and spillage.
Authors also emphasized the long-term eects of gallstone
spillage after LC. The long follow-up period (mean, 3.3 y) and
the low rate of complications was remarkable. The treatment of
complications by percutaneous techniques without surgical
intervention is not discussed in this study.
Sarli et al6 reported a matched-cohort analytic study of
131 patients with intraoperative perforation of 1127 LC
patients and compared them with another 131 patients without
perforation. The study design was focused on the complica-
tions and morbidities. They reported 26 unretrieved gallstones
among the patient group. The authors reported statistical dif-
ference within the duration of surgery (longer in the perforation
group) and surgeons experience was associated with the inci-
dence of perforation but no dierence in the postoperative
complications was reported. The methods were clearly dened
but the follow-up period was relatively short.
Memon et al7 reported 856 cases, 165 perforations (19%),
and 106 unretrieved gallstones in their study. The median
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 Volume 25, Number 2, April 2015
Complications (%) Retained Gallstones [n (%)]
36 0.08
39 1.3
43 3.8 26 (2.3)
44 4.7 106 (12)
0
1.9 40 (6.4)
52 0.04
22 0.35
121 0 24 (4)
follow-up time was 44 months and 4 patients developed com-
plications due to retained gallstones. All of the patients were
treated conservatively in this study. All the operations were
done by a single surgeon. The methods were clearly dened.
The study was prospectively designed, and the number of
complications was scarce. The review of the literature including
animal studies was included in the article.
Hui et al8 collected the data of 1412 patients who had
undergone LC and found 512 iatrogenic perforations. They
found male sex, weight, gallbladder inammation, thick-
ening of gallbladder, presence of adhesions, and a dicult
dissection associated with increased incidence of gall-
bladder perforation. The authors reported only 2 patients
with abdominal abscesses. The incidence of the spilled
gallstones were not reported in the study.
Diez et al9 reported 40 unretrieved gallstones of 3686
patients. They stated that 12 patients developed complica-
tions and 10 patients had to be reoperated. In 7 patients
stones were left at trocar sites. The authors concluded that
there was no need for routine conversion to open surgery in
the case of perforation of gallbladder and spillage of gall-
stones. This series was performed by 6 dierent surgeons
and the level of experience was not dened in the study. The
study was a retrospective study and the statistical methods
were not clearly identied.
Hawasli et al10 discussed the results of 5526 LCs and
reported 2 patients having complications due to spillage of
gallstones. They reported abscesses in 2 patients located
around the liver occurring 4 years and 4 months after the
operation. The other complication was also an abscess
around the liver occurring after 2 years from the operation.
The conclusion of the article was to emphasize the
importance of prevention of spillage of gallstones; in the
occurrence of spillage, irrigation and retrieval of the gall-
stones should be performed.
Horton and Florence11 evaluated 1130 LCs and found
4 patients who subsequently developed intra-abdominal
abscesses as a consequence of spilled gallstones during LC.
All of these patients required surgical abscess drainage and
postoperative antibiotics. Follow-up time ranged from 3
months to 5 years. Also, the culture results of each patient
were dened and the recurrent abscess drainage was per-
formed and advised. However, the authors stated that
thorough irrigation in case of perforation does not prevent
formation of abscess in the abdomen. This study reports a
series which were performed by 16 dierent surgeons and
the experience of each was not dened in the study.
Manukyan et al12 reported 580 LCs, 101 perforations
(17%), and 24 retained gallstones. Twenty-two patients with
r 2014 Wolters Kluwer Health, Inc. All rights reserved.
Surg Laparosc Endosc Percutan Tech  Volume 25, Number 2, April 2015
retained stones were investigated after a median follow-up of
121 months. Retained gallstones were shown radiologically in
2 of the patients without any harmful eects. The authors
concluded that whenever possible all the gallstones should be
retrieved. When not possible, irrigation of the surgical area
together with a short course of oral antibiotics seemed to be
eective in preventing potential complications. The follow-up
time is the longest among the studies. The number of compli-
cations was very low and there was no need for surgical
intervention or percutanous drainage.
LC is the most commonly performed abdominal surgical
procedure. The reported series clearly reveal that the perfo-
ration of the gallbladder and spillage of gallstones are not rare
during LC depending on the level of the experience of the
surgeon and the anatomy of the gallbladder. With perforation
and spillage of gallstones, losing some of the spilled gallstones
seems inevitable. Although rare, the retained stones can cause
serious complications and therefore every eort must be made
to avoid perforation and spillage. When all spilled stones are
not retrieved completely, copious irrigation of the surgical area
and use of antibiotics are the most commonly performed
procedure. Conversion to open surgery is not recommended at
this point.
Studies have shown that retained stones at trocar sites
cause a higher incidence of infectious complications. Therefore,
routine use of bags during the retrieval of gallbladders seems to
be a safe way to avoid this complication.9,14
CONCLUSIONS
Perforation of the gallbladder and spillage of the
gallstones is a rare source of morbidity after LC. If all
spilled gallstones can not be retrieved, conversion to open
procedure is not recommended.
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Retained Abdominal Gallstones After LC
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