AB010. Post-cholecystectomy syndrome and cystic duct stump calculus in post cholecystectomy: a surgical bizarre

Background: The gallbladder remnant and the cystic duct stump calculus are uncommon cause of post-cholecystectomy syndrome. Varied presentation and complex of symptoms and Situational skilled management leads to post event syndrome. Incidence of incomplete Gallbladder removal following conventional cholecystectomy appears very low in the era of active management by laparoscopic cholecystectomy. There is paucity of literature on this problem and is limited to few case reports and series. The aim of our study is to do literature search for “Residual gallbladder and cystic duct stump calculus”: (I) to determine its problem status in surgery; (II) to analyze the etio-pathogenesis; (III) preventive measures and its management.

Methods: It is an analytical study of data comprising seven case series, which have five or more patients after combining all the worldwide studies there are 130 patients. Surprisingly, five of these studies are from our country that combined 110 patients out of 130 patients (84.6%). Symptoms reappear from few months to many years after the surgery right upper quadrant abdominal pain with or without jaundice.

Results: Analysis of these literatures pointed for correctible reasons (incomplete dissection of cystic duct leaving calculus within it and reformation of calculus after subtotal cholecystectomy accounting for incomplete dissection). (I) Poor visualization of gallbladder fossa during surgery, excessive bleeding (cirrhosis), acute local inflammation, fibrosis; (II) inadequate dissection due to surgical skills, training and infrastructures. Non-correctible factors contributing were anatomical variations, dense Fibrosis, adhesions, concurrent inflammation, recurrent biliary colic, pancreatitis, comorbid conditions and finally surgical egoism. Subsequently there is an emergent need of assessment; active skilled intervention and formulation of prevention strategy and guideline are needed to overcome such bizarre.

Conclusions: Skillful anatomical dissection and clinical skeletonisation of cystic duct starting from gallbladder infundibulum to one cm from common bile duct and inadequate dissection techniques, skills, training and set ups can be overcome by dedicated laparoscopic training under the supervision of experts.

Keywords: Post cholecystectomy syndrome; residual gall stone; surgical skill; gall bladder fossa; surgical training