Laparoscopic Management of Remnant Cystic Duct Calculi: A Retrospective Study

Abstract

INTRODUCTION Even though cholecystectomy relieves symptoms in the majority of cases, a significant percentage suffer from 'post-cholecystectomy syndrome'. Cystic duct/gall bladder remnant calculi is a causative factor. We present our experience with the laparoscopic management of cystic duct remnant calculi. PATIENTS AND METHODS We managed 15 patients with cystic duct remnant calculi from 1996 to 2007 in our institute. All these patients had earlier undergone laparoscopic subtotal cholecystectomy at our centre. They were successfully managed by laparoscopic excision of the remnant. RESULTS The mean duration between first and second surgery was 8.35 months (range, 6-10.7 months). The mean operating time was 103.5 min (range, 75-132 min). Duration of hospital stay was 4-12 days. There was a higher incidence of remnant duct calculi following laparoscopic subtotal cholecystectomy than conventional laparoscopic cholecystectomy -13/310 (4.19%) versus 2/9590 (0.02%). The morbidity was 13.33%, while there were no conversions and no mortality. CONCLUSIONS Leaving behind a cystic duct stump for too long predisposes stone formation, while dissecting too close to the common bile duct and right hepatic artery in acute inflammatory conditions is dangerous. We believe that the former is a wiser policy to follow, as cystic duct remnant calculi are easier to manage than common bile duct or vessel injury. Laparoscopic excision of the remnant is effective, especially when performed by experienced laparoscopists. 'T'-tube is used to canulate the common bile duct in case the tissue is friable. Magnetic resonance cholangiopancreaticography is the imaging modality of choice, and is mandatory.

Association Between Gall Bladder Diameter and Calculus in the Cystic Duct in Gall Stone Diseases and Its Importance in the Current Surgical Practice- A Crosssectional Study in Jnims, Porompat, Manipur

“…(6) Palanivelu C, Rangarajan M, Jategaonkar PA, et al observed that in Acute Cholecystitis with Cholelithiasis, sometimes a long cystic duct stump was left behind instead of dissecting too close to the common bile duct and right hepatic artery which again can be a predisposing factor for stone formation. (7) In Sezeur A and Akel K study, Cystic duct stone is found frequently during cholecystectomy, so the surgeon's team needs proper preoperative evaluation of the cystic duct and also careful ligation of the cystic duct at its junction from common hepatic duct. (8) Benninger J, Rabenstein T and Farnbacher M et al showed successfully managed post-operative cystic duct remnant stone by extracorporeal shockwave lithotripsy along with the endoscopic removal of the stone fragments.…”

Laparoscopic subtotal cholecystectomy for severe cholecystitis

“…The follow-up period appears sufficient to capture almost all of the late complications associated with residual stones [40][41][42], but may be too short to detect problems associated with the remnant gallbladder, such as newly formed gallstones or postcholecystectomy syndrome [43].…”

Peroral cholangioscopy-assisted guidewire placement for removal of impacted stones in the cystic duct remnant

“…This study reports the experience of using this device for removal of impacted stones in the cystic duct remnant. Most symptomatic patients with calculi in the cystic duct remnant undergo laparoscopic re-operation for stone management [17][18][19] . In this case, this peroral cholangioscopy system was used to place a guidewire in the cystic duct remnant under direct visualization after a failed attempt during ERCP, with subsequent removal of an impacted calculus.…”