DOI:10.2214/AJR.07.3602
AJR 2008; 191:783-789
© American Roentgen Ray Society
Spectrum of Biliary and Nonbiliary Complications After Laparoscopic Cholecystectomy: Radiologic Findings
Ji Yeon Kim1,
Kyoung Won Kim1,
Chul-Soo Ahn2,
Shin Hwang2,
Young-Joo Lee2,
Yong Moon Shin1 and
Moon-Gyu Lee1
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.
Received December 29, 2007;
accepted after revision March 7, 2008.
Address correspondence to K. W. Kim
(kimkw{at}amc.seoul.kr).
Abstract
OBJECTIVE. The purpose of this article is to illustrate the
radiologic features of various biliary and nonbiliary complications after
laparoscopic cholecystectomy.
CONCLUSION. Various complications should be considered in patients
who do not make an uneventful postoperative recovery after laparoscopic
cholecystectomy. Sonography is the easiest and most noninvasive method for
screening for such complications. MR cholangiography is most effective in
showing biliary complications and CT, for the evaluation of nonbiliary
complications. Endoscopic retrograde cholangiography enables not only detailed
biliary estimation but also biliary decompression.
Keywords: complications • laparoscopic cholecystectomy • MDCT • MR cholangiography
Introduction
The frequency of laparoscopic cholecystectomy has increased over recent
decades. Although it is generally safe, this procedure may cause a spectrum of
complications with a variable degree of morbidity. Because the safety of the
procedure is of utmost concern, radiologists should note possible injuries
during laparoscopic cholecystectomy and their radiologic appearance to make an
early diagnosis of these complications and minimize morbidity. In this
article, we illustrate the radiologic features of various complications after
laparoscopic cholecystectomy.
Stone Retention in the Remnant Gallbladder or Cystic Duct
Although uncommon, laparoscopic cholecystectomy may be performed with
incomplete excision of the gallbladder when there is surgical difficulty due
to vascularized adhesion [1].
Such cases may sometimes result in stone retention in the remnant gallbladder
(Fig. 1A,
1B). Similarly, because there
are limitations in exploring the cystic duct pedicle during laparoscopic
cholecystectomy, a small stone in a particularly long cystic duct may remain
after laparoscopic cholecystectomy (Fig.
2A,
2B).
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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.
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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.
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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.
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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).
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MR cholangiography (MRC) may be an effective method for depicting the
remnant gallbladder or cystic duct stones
[2]. Sonography and unenhanced
CT can also show the retained stones and wall thickening of the remnant
gallbladder or cystic duct.
Common Bile Duct Stones
Although MRC is valuable for preoperative evaluation of common bile duct
(CBD) stones before laparoscopic cholecystectomy
[3], this examination is not
routinely performed in many institutions because of cost–benefit
concerns. CBD exploration is impossible during laparoscopic cholecystectomy.
Therefore, unexpected CBD stones may cause biliary obstruction after
laparoscopic cholecystectomy
[4]. Rarely, small gallbladder
stones may migrate into the CBD in patients with a patulous cystic duct when
the gallbladder is pulled in a cephalad direction during its dissection (Fig.
3A,
3B,
3C,
3D). Endoscopic retrograde
cholangiography (ERC) is effective in diagnosing such cases and can offer
therapeutic options as well.
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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.
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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.
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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.
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Bile Leakage
Bile leakage is the most common complication of laparoscopic
cholecystectomy [5,
6]. Most leaks occur from the
cystic duct stump. Unintentional laceration, transection, or thermal injury of
an unrecognized anomalous duct may also result in bile leakage
[7].
Although cross-sectional imaging studies can show a biloma in the
gallbladder fossa, their value is limited because they may not reveal active
bile leakage. Hepatobiliary scintigraphy, ERC, or percutaneous transhepatic
cholangiography (PTC) can show an active bile leak and the leakage site (Fig.
4A,
4B,
4C,
4D). Recently, it has been
proposed that mangafodipir trisodium–enhanced T1-weighted MRC is
effective in showing bile leakage
[8] (Fig.
5A,
5B).
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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.
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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.
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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.
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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).
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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).
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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.
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Acute Biliary Obstruction and Bile Duct Injury
Acute biliary obstruction and bile duct injury is twice as common with
laparoscopic cholecystectomy as with open cholecystectomy
[9]. The classic injury occurs
when the surgeon mistakes the common hepatic duct (CHD) for a cystic duct; the
CHD is then clipped, resulting in acute biliary obstruction. In addition,
failure to recognize the anomalous bile ducts can lead to injury of these
ducts [7].
In these patients, radiologic studies usually show diffuse or segmental
intrahepatic duct dilatation and surgical clips at the point of obstruction.
In patients with CHD obstruction, ERC usually shows no opacification of the
CHD proximal to the surgical clips, and PTC shows dilatation of the
intrahepatic duct and CHD with an abrupt cutoff at the surgical clips (Fig.
6A,
6B). In patients with an
aberrant duct injury, PTC shows dilatation and an abrupt cutoff of the
segmental intrahepatic duct, which is the "missing" duct on ERC
(Fig. 7A,
7B,
7C,
7D). MRC allows accurate
classification of these injuries
[10].
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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.
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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).
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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).
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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).
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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.
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Late Biliary Obstruction with Stricture
Recently, the incidence of late strictures of extrahepatic ducts has
substantially increased, perhaps from the widespread use of laparoscopic
cholecystectomy [11]. As
mentioned previously, thermal injury may result in acute bile duct necrosis
and bile leakage, but mild injury may result in fibrosis
[7]. Also, the clips rarely
induce fibrosis or inflammatory changes around the extrahepatic ducts that
might cause a stricture [6].
Although MRC is the most effective noninvasive method for diagnosis of a
biliary stricture [10], ERC
provides both diagnostic and therapeutic options.
Bleeding
Bleeding may occur from the cystic artery stump and the right hepatic
artery after laparoscopic cholecystectomy. It may result from thermal or
mechanical injury of these arteries, which are occasionally associated with
bile duct injury [5]. An
arterial pseudoaneurysm is also rarely encountered
[12].
MDCT is the most effective method for detecting bleeding because it may
reveal a focus of active bleeding or a pseudoaneurysm on contrast-enhanced
scans (Fig. 8A,
8B). Transcatheter arterial
embolization or surgical hemostasis should be considered according to the
amount and rate of bleeding when extravasation of the IV contrast agent is
seen on dynamic CT. Conventional angiography is also warranted in highly
suspicious cases even without this finding.
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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).
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Abscess with Retention of Peritoneal Gallstones or Spilled Clips
Bile and gallstone spillage due to gallbladder perforation is a common
problem during laparoscopic cholecystectomy that occurs in approximately 35%
of patients [13]. Subsequent
abscess has been reported to occur in 0.6% of cases in which bile spillage
alone occurs and in 0.6–2.9% of cases in which both bile and calculus
spillage occurs [13,
14]. Similar presentations
caused by spilled clips have also been described
[14]. Although most abscesses
associated with unretrieved peritoneal gallstones or spilled clips are seen in
the perihepatic space, they may occur anywhere in the peritoneal cavity
[5].
The visualization of a spilled stone or clip in the abscess is the key to
radiologic diagnosis of this entity. Such an abscess is seen as an echogenic
focus with posterior acoustic shadowing on sonography and as a central or
eccentric nidus with calcific or metallic density on CT
[14] (Figs.
9A,
9B,
9C and
10A,
10B). Rarely, chronic abscess
may mimic a malignancy (Fig.
11A,
11B,
11C,
11D).
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Trocar-Site Hernia
An umbilical hernia at the site of a midline trocar is the most common type
of trocar-site hernia [15],
which generally occurs within a few days after surgery, often with small-bowel
obstruction. However, symptomatic onset produced by a trocar-site hernia can
range from a few to several months after surgery
(Fig. 12).
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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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CT is useful in patients with a trocar-site hernia. Additional surgery is
required in cases associated with small-bowel obstruction and strangulation or
impending strangulation. Although it is rare, a trocar-site hernia may be
complicated by panniculitis.
Conclusion
Various complications should be considered in patients who do not make an
uneventful postoperative recovery after laparoscopic cholecystectomy.
Sonography is the easiest and most noninvasive method for screening for such
complications. MRC is most effective in showing biliary complications and CT,
for the evaluation of nonbiliary complications. ERC enables not only detailed
biliary estimation but also biliary decompression.
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Abstract
Introduction
