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Spectrum of Biliary and Nonbiliary Complications After Laparoscopic Cholecystectomy: Radiologic Findings

¹ Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Pungnap 2-dong, Songpa-ku, Seoul 138-736, South Korea.
² Department of Surgery, Asan Medical Center, University of Ulsan, Seoul, South Korea.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —62-year-old woman with recurrent right upper quadrant pain 2 years after laparoscopic cholecystectomy. No cystic duct was identified on pathologic examination of specimen obtained at laparoscopic cholecystectomy. Oblique sagittal sonogram shows round echogenic lesion with posterior acoustic shadowing (arrow) in saccular anechoic structure in gallbladder fossa, posterior to multiple linear echogenic lesions with shadowing (arrowheads). These findings suggest diagnosis of retained stone in remnant gallbladder.

View larger version (147K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —62-year-old woman with recurrent right upper quadrant pain 2 years after laparoscopic cholecystectomy. No cystic duct was identified on pathologic examination of specimen obtained at laparoscopic cholecystectomy. Axial contrast-enhanced CT scan shows radiopaque stone (arrow) in remnant gallbladder (asterisk) and multiple surgical clips (arrowhead) lodged further anteriorly than usual in laparoscopic cholecystectomy.

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —41-year-old woman with epigastric pain 5 years after laparoscopic cholecystectomy. T2-weighted MR cholangiogram obtained using single-shot RARE sequence shows retained stone (arrowhead) in remnant cystic duct.

View larger version (154K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —41-year-old woman with epigastric pain 5 years after laparoscopic cholecystectomy. On endoscopic retrograde cholangiogram, retained cystic duct stone is seen as filling defect (arrowhead).

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —19-year-old woman with abdominal pain 2 days after laparoscopic cholecystectomy. Preoperative T2-weighted axial MR image shows multiple small gallstones (arrow) and edematous wall thickening of gallbladder.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —19-year-old woman with abdominal pain 2 days after laparoscopic cholecystectomy. MR cholangiogram shows two stones in common bile duct (arrows).

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —19-year-old woman with abdominal pain 2 days after laparoscopic cholecystectomy. Before laparoscopic cholecystectomy, common bile duct stones were endoscopically removed and endoscopic retrograde cholangiogram shows no evidence of residual stone in common bile duct. However, surgical specimen of gallbladder removed at laparoscopic cholecystectomy did not contain numerous gallstones seen on preoperative MR cholangiogram.

View larger version (149K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3D —19-year-old woman with abdominal pain 2 days after laparoscopic cholecystectomy. Endoscopic retrograde cholangiogram obtained on postoperative day 2 shows several small stones in common bile duct. In this patient, it is presumed that small gallbladder stones may have migrated into common bile duct through patulous cystic duct during laparoscopic cholecystectomy.

View larger version (186K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —59-year-old woman with abdominal pain 1 month after laparoscopic cholecystectomy. Oblique coronal MR cholangiogram obtained with RARE sequence shows abnormal fluid collection in gallbladder fossa extending to perihepatic space (arrowheads). Stricture (arrow) and dilatation of right posterior segmental duct are also noted.

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —59-year-old woman with abdominal pain 1 month after laparoscopic cholecystectomy. Right posterior segmental duct (arrow) presents as "missing" duct on endoscopic retrograde cholangiogram.

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —59-year-old woman with abdominal pain 1 month after laparoscopic cholecystectomy. On hepatobiliary scintigraphy using diisopropyl iminodiacetic acid, accumulation of radionuclide is seen in gallbladder fossa and perihepatic space, thereby suggesting active bile leakage.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4D —59-year-old woman with abdominal pain 1 month after laparoscopic cholecystectomy. Percutaneous transhepatic cholangiogram shows contrast leakage (arrowheads) around surgical clips from right posterior segmental bile duct (arrow).

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —41-year-old man with jaundice 5 days after laparoscopic cholecystectomy. Oblique coronal MR cholangiogram obtained using RARE sequence shows cutoff common bile duct (arrows) surrounded by fluid collection (arrowhead).

View larger version (161K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —41-year-old man with jaundice 5 days after laparoscopic cholecystectomy. Coronal 3D volumetric interpolated T1-weighted gradient-echo MR image obtained 30 minutes after injection of mangafodipir trisodium shows enhancement of intrahepatic duct and common hepatic duct (arrow), as well as extravasation of contrast agent (arrowhead). Mangafodipir trisodium does not excrete into common bile duct.

View larger version (129K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —58-year-old man with jaundice 6 days after laparoscopic cholecystectomy. Axial contrast-enhanced CT scan shows diffuse dilatation of intrahepatic bile duct.

View larger version (149K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —58-year-old man with jaundice 6 days after laparoscopic cholecystectomy. Endoscopic retrograde cholangiogram shows no opacification of bile duct proximal to surgical clips. Clips are misplaced on common bile duct because it was mistaken for cystic duct on laparoscopic cholecystectomy.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —51-year-old man with increased liver enzyme 6 months after laparoscopic cholecystectomy. Axial contrast-enhanced CT scan shows dilatation of right posterior segmental duct abutting surgical clips (arrow).

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —51-year-old man with increased liver enzyme 6 months after laparoscopic cholecystectomy. Oblique coronal MR cholangiogram obtained with RARE sequence shows segmental dilatation of aberrant right posterior segmental bile duct that drains into common hepatic duct and stricture in proximal portion of aberrant duct (arrow).

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C —51-year-old man with increased liver enzyme 6 months after laparoscopic cholecystectomy. Percutaneous transhepatic cholangiogram shows dilatation and abrupt cutoff of right posterior segmental duct abutting on surgical clips (arrow).

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7D —51-year-old man with increased liver enzyme 6 months after laparoscopic cholecystectomy. On endoscopic retrograde cholangiogram, a clip (arrow) is seen to be lodged between dilated right posterior segmental duct and common hepatic duct.

View larger version (155K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —28-year-old man with hypotension 1 day after laparoscopic cholecystectomy. Axial contrast-enhanced CT scan shows small suspicious pseudoaneurysm (arrowhead) in gallbladder fossa adjacent to surgical clip (arrow).

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —28-year-old man with hypotension 1 day after laparoscopic cholecystectomy. Transcatheter hepatic arteriogram shows small pseudoaneurysm (arrowhead) arising from right hepatic artery.

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —55-year-old man with fever and chills 1 month after laparoscopic cholecystectomy. Unenhanced (A) and contrast-enhanced (B) CT scans show large abscess involving right hepatic lobe (asterisk, B) and calcific nidus in Morison's pouch (arrow, A), suggesting abscess related to unretrieved peritoneal gallstones.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —55-year-old man with fever and chills 1 month after laparoscopic cholecystectomy. Unenhanced (A) and contrast-enhanced (B) CT scans show large abscess involving right hepatic lobe (asterisk, B) and calcific nidus in Morison's pouch (arrow, A), suggesting abscess related to unretrieved peritoneal gallstones.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9C —55-year-old man with fever and chills 1 month after laparoscopic cholecystectomy. Spilled clip (arrowhead) is also noted in right subhepatic area on contrast-enhanced CT scan.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —66-year-old man with fever 4 months after laparoscopic cholecystectomy. Axial contrast-enhanced CT scan shows abscess (arrowheads) involving right hepatic lobe, perihepatic space, and posterior abdominal wall. Note also that abscess surrounds a spilled surgical clip (arrow) in Morison's pouch.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —66-year-old man with fever 4 months after laparoscopic cholecystectomy. Oblique coronal sonogram shows heterogeneous echogenicity of abscess (long arrows) and central echogenic focus (short arrow) with posterior acoustic shadowing (arrowheads) corresponding to spilled clip.

View larger version (101K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —55-year-old man with liver mass 8 months after laparoscopic cholecystectomy. Patient is hepatitis B carrier. His early postoperative period was uneventful. Unenhanced (A) and contrast-enhanced (B) CT scans show ill-defined spiculated mass involving right posteroinferior hepatic lobe, perihepatic space, and posterior abdominal wall, with mild contrast enhancement. Also note central niduses with calcific density (arrow, A). On CT, because of mild contrast enhancement and ill-defined margin of lesion as well as patient's underlying liver disease, this was radiologically misdiagnosed as hepatocellular carcinoma even though there was a central nidus with calcific density.

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —55-year-old man with liver mass 8 months after laparoscopic cholecystectomy. Patient is hepatitis B carrier. His early postoperative period was uneventful. Unenhanced (A) and contrast-enhanced (B) CT scans show ill-defined spiculated mass involving right posteroinferior hepatic lobe, perihepatic space, and posterior abdominal wall, with mild contrast enhancement. Also note central niduses with calcific density (arrow, A). On CT, because of mild contrast enhancement and ill-defined margin of lesion as well as patient's underlying liver disease, this was radiologically misdiagnosed as hepatocellular carcinoma even though there was a central nidus with calcific density.

View larger version (90K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11C —55-year-old man with liver mass 8 months after laparoscopic cholecystectomy. Patient is hepatitis B carrier. His early postoperative period was uneventful. 18F-FDG PET reveals hypermetabolic lesion in corresponding region.

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11D —55-year-old man with liver mass 8 months after laparoscopic cholecystectomy. Patient is hepatitis B carrier. His early postoperative period was uneventful. Oblique sagittal sonogram from sonographically guided biopsy shows ill-defined mass (short arrows) in right inferior tip of liver. Central echogenic foci (long arrow) with posterior shadowing (arrowheads), corresponding to spilled stones, are also revealed. Histopathologic diagnosis was necrotizing granuloma by spilled stones, and surgery was thereby avoided.

View larger version (134K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12 —70-year-old woman with palpable mass and abdominal pain in periumbilical area after laparoscopic cholecystectomy. Axial contrast-enhanced CT scan shows relatively large dehiscence of anterior and posterior fascial plane at umbilical trocar site (arrows) as well as herniation of omentum (arrowheads). Increased attenuation of herniated omental fat and presence of clinical symptoms may suggest panniculitis, which was subsequently confirmed on histopathologic examination.

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