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Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited renal disorder. ADPKD is not only associated with progression of renal disease, but also several hepatobiliary manifestations. This report is of a 49-year-old female with recurrent cholelithiasis and cholecystitis following subtotal cholecystectomy in the context of aberrant biliary anatomy and ADPKD. There were significant adhesions obscuring the cystic duct, necessitating the second cholecystectomy be performed open. The right posterior hepatic duct was adhered to the gallbladder wall and was perforated while attempting to remove the gallbladder remnant. The duct was repaired over a T-tube, without any subsequent biliary leak. The cystic duct was hugely dilated and impacted with stones down to the junction with the common bile duct, which were evacuated, and the cystic duct was oversewn along with the remnant of the gallbladder wall. The recovery course was unremarkable.

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Background: Subtotal cholecystectomy was described in 1985 as an alternative to total cholecystectomy in cases of difficult cholecystectomy. It was classified as reconstituted and fenestrated subtotal. In spite of being a viable alternative, up to 10.6% of biliary leakage is reported and 2.2% of patients present with cholecystitis of the gallbladder remnant. The objective of this report is to describe and emphasize the importance of an adequate diagnosis of complications in patients with a history of subtotal cholecystectomy. Clinical case: 72-year-old male with a history of open subtotal cholecystectomy 6 years prior to his admission to the emergency department due to right hypochondrium pain and vomiting. He had a history of biliary pancreatitis and choledocholithiasis after subtotal cholecystectomy resolved by endoscopic retrograde cholangiopancreatography (ERCP). It was decided to admit the patient and a diagnosis of cholecystitis of the gallbladder remnant was made. Laparoscopic cholecystectomy of the remnant was performed with subsequent clinical resolution. Conclusions: Although subtotal cholecystectomy may be the only option in cases of difficult cholecystectomy, it may result in future complications. The possibility of more complex surgical reinterventions should be considered. Our case report demonstrates that total cholecystectomy in cases of cholecystitis should be performed whenever possible to avoid potential complications caused by subtotal cholecystectomy.

Introducción: la colecistectomía subtotal fue descrita en 1985 como una alternativa a la colecistectomía total en casos de colecistectomía difícil. Fue clasificada como subtotal reconstituida y fenestrada. A pesar de ser una alternativa viable, se reporta hasta un 10.6% de fuga biliar y 2.2% de los pacientes presentan colecistitis del remanente vesicular. El objetivo de este reporte de caso es incluir la colecistitis del remanente vesicular como diagnóstico diferencial en pacientes con antecedente de colecistectomía subtotal y dolor abdominal. Caso clínico: hombre de 72 años con antecedente de colecistectomía subtotal abierta. Seis años antes de su ingreso, acudió a un servicio de urgencias por dolor en hipocondrio derecho y vómito. Contaba con antecedente de pancreatitis biliar y coledocolitiasis posterior a colecistectomía subtotal resueltas por colangiopancreatografía retrógrada endoscópica (CPRE). Se decidió ingresar al paciente y se integró diagnóstico de colecistitis del remanente de la vesícula biliar. Se realizó colecistectomía laparoscópica del remanente con posterior resolución clínica. Conclusiones: a pesar de que la colecistectomía subtotal puede ser la única opción en casos de colecistectomía difícil, esta puede resultar en complicaciones futuras. La posibilidad de reintervenciones quirúrgicas más complejas debe ser considerada. Con nuestro reporte de caso podemos inferir que la colecistectomía total en casos de colecistitis debe realizarse siempre que sea posible para evitar potenciales complicaciones causadas por la colecistectomía subtotal.

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OBJECTIVE: We aimed to investigate risk factors related to remnant gallbladder (RGB) stones. METHODS: This retrospective study included 73 patients with RGB, in groups with and without RGB calculi. Univariate analyses were used to identify nine variables associated with RGB calculi: sex, age, body mass index (BMI), time to detection, surgical method, length of RGB, angle of RGB and common hepatic duct (CHD), choledocholithiasis, and remnant cholecystitis. Multivariate logistic regression was performed to assess independent predictors of RGB stones. A receiver operating characteristic (ROC) curve was used to estimate model accuracy and determine cut-off values of independent predictors. RESULTS: We enrolled 73 patients, 33 with and 40 without RGB stones. Univariate analyses showed that age, BMI, time to detection, length of RGB, angle of RGB and CHD were predictors for RGB calculi. Multivariate analyses indicated that time to detection, length of RGB, and angle of RGB and CHD were independent predictors for RGB calculi. The area under the ROC curve of the model was 0.940. Cut-off values of the three indicators were 1.5 years, 2.25 cm, and 22.5°, respectively. CONCLUSION: Time to detection, length of RGB, and angle of RGB and CHD were independent predictors of RGB calculi.

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INTRODUCTION: Retrieval bags are used in laparoscopic cholecystectomies to reduce the risk of bile and gallstone spillage during removal of the gallbladder. Retrieval bag rupture is rare, and its complications have never been previously documented. PRESENTATION OF CASE: A 17-year-old female presented three months post-laparoscopic cholecystectomy with a tender periumbilical mass. Her operative report noted difficulty removing the retrieval bag from the infra-umbilical port site. Imaging of the lump revealed an intra-abdominal fluid collection communicating with the umbilicus. A diagnostic laparoscopy uncovered significant pus in the peritoneal cavity and a gallbladder remnant with multiple gallstones. A combination of sharp and blunt dissections was used to free the gallbladder remnant from its adherent surroundings for removal. A peritoneal washout was performed following extraction of the retained gallstones. The patient's presentation could be traced back to her laparoscopic cholecystectomy where it was confirmed that the retrieval bag ruptured during removal. This would have transected the gallbladder, causing its remnants and associated gallstones to be retained in the peritoneal cavity. DISCUSSION: Retrieval bag rupture can result in retained gallbladder remnants in the peritoneal cavity. Abdominal abscess can manifest months after the initial operation. CONCLUSION: Retrieval bags should be inspected following removal to ensure it is completely intact. Surgeons should consider extending the fascial incision if there is any difficulty during removal. Any damage to the retrieval bag mandates immediate pneumoperitoneum for further exploration of retained products. Governance bodies should incorporate practice guidelines related to retrieval bag rupture as these are currently not present.

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BACKGROUND: Incomplete gallbladder removal following open and laparoscopic techniques leads to residual gallbladder stones. The commonest presentation is abdominal pain, dyspepsia and jaundice. We reviewed the literature to report diagnostic modalities, management options and outcomes in patients with residual gallbladder stones after cholecystectomy. MATERIALS AND METHODS: Medline, Google and Cochrane library between 1993 and 2013 were reviewed using search terms residual gallstones, post-cholecystectomy syndrome, retained gallbladder stones, gallbladder remnant, cystic duct remnant and subtotal cholecystectomy. Bibliographical references from selected articles were also analyzed. The parameters that were assessed include demographics, time of detection, clinical presentation, mode of diagnosis, nature of intervention, site of stone, surgical findings, procedure performed, complete stone clearance, sequelae and follow-up. RESULTS: Out of 83 articles that were retrieved between 1993 and 2013, 22 met the inclusion criteria. In most series, primary diagnosis was established by ultrasound/computed tomography scan. Localization of calculi and delineation of biliary tract was performed using magnetic resonance imaging/magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography. In few series, diagnosis was established by endoscopic ultrasound, intraoperative cholangiogram and percutaneous transhepatic cholangiography. Laparoscopic surgery, endoscopic techniques and open surgery were the most common treatment modalities. The most common sites of residual gallstones were gallbladder remnant, cystic duct remnant and common bile duct. CONCLUSION: Residual gallbladder stones following incomplete gallbladder removal is an important sequelae after cholecystectomy. Completion cholecystectomy (open or laparoscopic) is the most common treatment modality reported in the literature for the management of residual gallbladder stones.