Technical Approach to Laparoscopic Examination of the Small Bowel in Gallstone Ileus

Abstract

Background. Gallstone ileus is an infrequent cause of small bowel obstructions (SBO), accounting for only 0.1-5% of SBOs and 25% of nonstrangulating causes of SBO in the elderly population. There is scant literature available regarding the use of laparoscopy to treat gallstone ileus. Currently, much of the literature available is limited to case reports only. Methods. A complete laparoscopic approach was utilized to manage a 65-year-old woman with morbid obesity who presented with gallstone ileus. With regard to our technical approach, we describe the technical approach that facilitates safe laparoscopic examination of the entire small bowel and can be applied to other acute care surgery cases involving small bowel pathology. Results. The patient’s postoperative course was complicated by new-onset atrial fibrillation which was treated medically with good response. She was safely discharged on postoperative day 2. Conclusion. Laparoscopy is a feasible option for the management of gallstone ileus and can lead to decreased morbidity compared to laparotomy. The technique described allows for laparoscopic examination of the entire small bowel.

Gallstone Ileus Caused by Migration of Gallstone Through Cholecystoduodenal Fistula Resulting in Small Bowel Obstruction

“…Gallstone ileus is usually treated with laparotomy, but it has high morbidity and mortality rates. Laparoscopy has emerged as a feasible alternative, with lower morbidity and faster recovery [ 11 , 14 , 15 , 16 ]. Therapeutic endoscopy is an option for patients with colonic gallstone ileus or Bouveret syndrome, but it is technically challenging and unsuccessful in up to 91% of cases.…”

Laparoscopic management of gallstone ileus: A case report and literature review

“…The GI is secondary at the migration of a gallstone to the bowel through a fistula [7] , [9] , [10] , [13] , formed due a chronic inflammation in the gallbladder and the local pressure by the gallstone against, most frequently, the small bowel [8] , [9] , [13] . The cholecytoduodenal fistula is the most common, in 85% of the cases, followed by cholecystogastric, cholecystojejunal and cholecystocolonic [1] , [3] , [5] , [12] , [13] , [14] .…”

“…Nevertheless, recurrence rate of GI after enterolithotomy alone is 5%, reoperation for calculous biliary disease occurs in less than 10% of patients and there are cases of spontaneous cholecysto-enteric fistula closure [1] , [11] . Considering this, enterotomy with stone extraction alone is the most common surgical treatment, because of its low complication rate [2] , [4] , [5] , [8] , [9] , [13] .…”

“…It occurs when a gallstone becomes lodged between the gallbladder and the bowel, forming a cholecysto-enteric fistula, with impaction of the gallstones at different levels of the gastrointestinal tract [1] , [2] , [3] , [4] , [6] , [7] , [8] , [9] , [10] , [11] .…”

“…The mortality and morbidity is still high nowadays, mostly given by the elderly population affected, late presentation from the onset of symptoms and the difficulty to make the diagnosis [1] , [2] , [3] , [8] , [12] , [13] .…”