Early cross-sectional imaging following open and laparoscopic cholecystectomy: a primer for radiologists

Abstract

Performed on either an elective or urgent basis, cholecystectomy currently represents the most common abdominal operation due to the widespread use of laparoscopy and the progressively expanded indications. Compared to traditional open surgery, laparoscopic cholecystectomy minimised the duration of hospitalisation and perioperative mortality. Albeit generally considered safe, cholecystectomy may result in adverse outcomes with non-negligible morbidity. Furthermore, the incidence of worrisome haemorrhages and biliary complications has not been influenced by the technique shift. Due to the growing medico-legal concerns and the vast number of cholecystectomies, radiologists are increasingly requested to investigate recently operated patients. Aiming to increase familiarity with post-cholecystectomy cross-sectional imaging, this paper provides a brief overview of indications and surgical techniques and illustrates the expected early postoperative imaging findings. Afterwards, most iatrogenic complications following open, converted, laparoscopic and laparo-endoscopic rendezvous cholecystectomy are reviewed with examples, including infections, haematoma and active bleeding, residual choledocholithiasis, pancreatitis, biliary obstruction and leakage. Multidetector computed tomography (CT) represents the “workhorse” modality to rapidly investigate the postoperative abdomen in order to provide a reliable basis for an appropriate choice between conservative, interventional or surgical treatment. Emphasis is placed on the role of early magnetic resonance cholangiopancreatography (MRCP) and additional gadoxetic acid-enhanced MRCP to provide a non-invasive anatomic and functional assessment of the operated biliary tract.Teaching Points• Having minimised perioperative mortality and hospital stay, laparoscopy has now become the first-line approach to performing cholecystectomy, even in patients with acute cholecystitis.• Laparoscopic, laparo-endoscopic rendezvous, converted and open cholecystectomy remain associated with non-negligible morbidity, including surgical site infections, haemorrhage, residual lithiasis, pancreatitis, biliary obstruction and leakage.• Contrast-enhanced multidetector computed tomography (CT) is increasingly requested early after cholecystectomy and represents the “workhorse” modality that rapidly provides a comprehensive assessment of the operated biliary tract and abdomen.• Magnetic resonance cholangiopancreatography (MRCP) is the best modality to provide anatomic visualisation of the operated biliary tract and is indicated when biliary complications are suspected.• Additional gadoxetic acid (Gd-EOB-DTPA)-enhanced MRCP non-invasively provides functional biliary assessment, in order to confirm and visualise bile leakage.

Laparoscopic Cholecystectomy Has Better Safety in Comparison to Open Surgery for Occurrence of Death and Myocardial Infarction

“…[18,20,25] It is also known that while LC is generally the safer method, there are areas that have not shown any improvement over OC, namely the incidence of post-cholecystectomy hemorrhage, or worse outcomes in the case of inter-operational biliary injuries. [4,15] Differences in the immune response to laparoscopic surgeries and their open counterparts have also been observed. It has often been found that patients undergoing laparoscopic surgeries experience less immunosuppression than those who have more traumatic, open surgeries.…”

Postoperative single-sequence (PoSSe) MRI: imaging work-up for CT-guided or endoscopic drainage indication of collections after hepatopancreaticobiliary surgery

“…These difficulties are more common in the early postoperative patient due to ileus, free air, and abdominal tenderness. That is why contrast-enhanced CT is often requested early and represents the “workhorse” imaging modality, enabling comprehensive assessment of the surgical site including detection of complications [ 10 ]. Abdominal MRI has established its value in the preoperative setting, allowing detailed tissue characterization in the upper abdomen (especially liver and also pancreatic).…”

“…Previous studies have shown that MRI has high sensitivity in the detection of abdominal fluid collections and that they indicate a surgical complication [ 12 ]. A recent study investigating postoperative complications in cholecystectomy recommends magnetic resonance cholangiopancreatography (MRCP) and also gadoxetic acid-enhanced MRCP to work-up suspected biliary complications and decide about the best management [ 10 ]. Especially in children, MRI should be preferred to avoid exposure to ionizing radiation.…”

MR Imaging of the Perihepatic Space

“…Depending on peritoneal anatomy and pressure gradients, abdominal infections are more likely to extend to the right side than to the left, and the perihepatic space, mainly the retrohepatic space, is regularly involved. Small foreign bodies, such as stercoliths left behind after an appendectomy, or dropped gallstones after a cholecystectomy, may get trapped in the perihepatic space, with subsequent formation of an abscess (12). The latter kjronline.org are generally small and discovered up to several years after the operation.…”