Hartmann's Pouch Stones and Laparoscopic Cholecystectomy: The Challenges and the Solutions

Abstract

Background & Objective: Hartmann's pouch stones (HPS) encountered during laparoscopic cholecystectomy (LC) may hinder safe dissection of the cystic pedicle or be complicated by mucocele, empyema, or Mirizzi syndrome; distorting the anatomy and increasing the risk of bile duct injury. We studied the incidence, presentations, operative challenges, and outcomes of HPS. Methods: A cohort study of a prospectively maintained database of LCs and bile duct explorations performed by a single surgeon. Patients were divided into two groups: those with HPS and those without. Patients' demographics, clinical presentation, intra-operative findings, and postoperative outcomes were compared. Results: Of the 5136 patients, 612 (11.9%) had HPS. The HPS group were more likely to present with acute cholecystitis (27.9% vs 5.9%, P ϭ .000) and more patients underwent emergency LC (50.7% vs 41.5%, P ϭ .000). The HPS group had more difficult cholecystectomies, with 46.1% vs 11.8% in the non-HPS group being operative difficulty grade 4 and 5. Mucocele, empyema, and Mirizzi syndrome were more common in the HPS group (24.0% vs 3.7% P ϭ .000, 30.9% vs 3.7% P ϭ .000, 1.8% vs 0.9% P ϭ .000, respectively). There was no significant difference in the open conversion rate or complications. Conclusion: HPS increase the difficulty of LC. Surgeons should be aware of their presence and should employ appropriate dissection strategies. Sharp or diathermy dissection should be avoided. Dislodging the stone into the gall bladder, stone removal, swab dissection, and cholangiography are useful measures to avoid ductal injury and reduce the conversion rate.

The impact of obesity on outcomes in patients undergoing emergency cholecystectomy for acute cholecystitis

“…Together, these added manoeuvres add towards the operative time. 27,29,30 Given the acute, high-risk nature of emergency operations, emergency general surgery patients are subject to higher rates of major postoperative complications and death when compared to those undergoing elective procedures. [31][32][33] These negative outcomes have been attributed to patient-specific factors including age, pre-existing comorbidities, and physiological abnormalities.…”

“…These findings may reflect a more severe inflammatory process observed in obese patients undergoing surgery for acute cholecystitis. It has been recognized that an impacted gallstone in Hartmann's pouch increases the operative difficulty of LC by causing severe oedema of the gallbladder wall that makes grasping and cephalad retraction difficult 27 . Large stones (≥1 cm) impacted in Hartmann's pouch also result in inflammatory processes around Calot's triangle.…”

“…Large stones (≥1 cm) impacted in Hartmann's pouch also result in inflammatory processes around Calot's triangle. Inflammation increases the risk of bleeding and injury to the biliary tree when attempting to expose the critical view of safety and thus creates additional challenges to surgery 27 . These technical challenges can be overcome by decompression of the gallbladder to drain the bile which reduces the gallbladder oedema created by the tense mucocele 28 .…”

“…In these situations where safe dissection of Calot's triangle cannot be achieved, surgical strategies to circumvent bile duct injury may include conversion to open surgery to allow the use of fingers to aid tactile feedback when dissecting severely inflamed tissues. Together, these added manoeuvres add towards the operative time 27,29,30 …”

“…It has been recognized that an impacted gallstone in Hartmann's pouch increases the operative difficulty of LC by causing severe oedema of the gallbladder wall that makes grasping and cephalad retraction difficult. 27 Large stones (≥1 cm) impacted in Hartmann's pouch also result in inflammatory processes around Calot's triangle. Inflammation increases the risk of bleeding and injury to the biliary tree when attempting to expose the critical view of safety and thus creates additional challenges to surgery.…”