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DOI:10.2214/AJR.07.3485
AJR 2008; 191:794-801
© American Roentgen Ray Society

Review

Laparoscopic Cholecystectomy: Postoperative Imaging

Peter D. Thurley1 and Rajpal Dhingsa

1 Both authors: Department of Radiology, Nottingham University Hospitals, Queens Medical Centre, Derby Rd., Nottingham, NG7 2UH, United Kingdom.

Received December 2, 2007; accepted after revision March 14, 2008.

 
Address correspondence to P. D. Thurley (pthurley{at}doctors.org.uk).

CME

This article is available for CME credit.

See www.arrs.org for more information.


Abstract
Top
 Abstract
Introduction
 Normal Appearances After...
 Biliary Complications
 Dropped Gallstones
 Vascular Complications
 Other Complications
 Summary
 References
 
OBJECTIVE. The purpose of this article is to describe the imaging findings after laparoscopic cholecystectomy, including the normal postoperative findings and the typical appearances of major complications. The relative merits of the imaging techniques available are discussed.

CONCLUSION. Laparoscopic cholecystectomy is a commonly performed surgical procedure and radiologists are often called on to identify or rule out postoperative complications. In such cases, the correct diagnosis is crucial in optimizing patient management.

Keywords: cholelithiasis • complications • laparoscopic cholecystectomy • normal findings


Introduction
Top
 Abstract
 Introduction
Normal Appearances After...
 Biliary Complications
 Dropped Gallstones
 Vascular Complications
 Other Complications
 Summary
 References
 
Laparoscopic cholecystectomy was first developed in Europe in the mid 1980s as an alternative to open cholecystectomy, a procedure that had been performed for more than a century. It has rapidly gained widespread popularity to become the procedure of choice for patients with symp tomatic cholelithiasis [1]. Laparoscopic cholecystectomy has advantages over open cholecystectomy, including a shorter hospital stay and an earlier return to normal activities [2]. However, complications after laparo scopic proce dures, especially bile duct injuries, have been reported to be more common [3], especially in the hands of less experienced surgeons [4]. A variety of other problems, including vascular injury, retained gallstones, and abscess formation, may also be encountered after laparoscopic cholecystectomy [3, 5–11] (Table 1).


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  		TABLE 1: Common Complications of Laparoscopic Cholecystectomy and Their Incidence

 

The correct use of radiologic tests can establish the type and site of postoperative complications, allowing timely intervention [12]. Sonography, CT, ERCP, MR cholangiopancreatography (MRCP), and radionuclide imaging all have a role to play in evaluating the postoperative patient [13, 14]. These investigations are often complementary and the primary imaging technique to be used will vary depending on the clinical problem faced. It is therefore important that radiol ogists are aware of the relative benefits of each investigation.

The aim of this article is to show the spectrum of imaging findings after laparoscopic chole cyst ectomy and provide examples of complications and normal findings. We also discuss the advan tages and disadvantages of the available radiologic investigations.


Normal Appearances After Laparoscopic Cholecystectomy
Top
 Abstract
 Introduction
 Normal Appearances After...
Biliary Complications
 Dropped Gallstones
 Vascular Complications
 Other Complications
 Summary
 References
 
Recognizing complications after laparoscopic cholecystectomy as soon as possible is advantageous because doing so allows prompt intervention and in turn may lead to an improved patient outcome [15]. To achieve this, a low threshold for requesting imaging studies is necessary, which is likely to result in many imaging studies that simply show the normal sequelae of laparoscopic cholecystectomy. The significance of imaging findings may vary considerably depending on the clinical findings; and it is important, as always, to interpret the imaging in the context of the patient's history, examination, and other test results.

Imaging studies may be required to look for evidence of biloma, abscess collections, or hematomas. However, not all fluid collections require intervention. A small amount of fluid in the surgical bed is commonly seen postoperatively on sono graphy [16], which in isolation does not justify percutaneous drainage. A small series that examined the CT appearances in un complicated laparoscopic cholecystectomy in six patients also found that 3–5 days after surgery fluid-density material is often seen in the gallbladder fossa (Fig. 1A, 1B). Small amounts of free pelvic fluid and increased density in the abdominal wall fat at the site of the laparoscopic ports were also often present [17].


Figure 1
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  		Fig. 1A —Normal appearances after cholecystectomy. CT scan of 53-year-old woman 2 days after laparoscopic cholecystectomy shows collection measuring 21 HU (consistent with fluid) is present within gallbladder fossa (arrow) adjacent to cholecystectomy clip. This is commonly seen after uncomplicated laparoscopic cholecystectomy.

 

Figure 2
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  		Fig. 1B —Normal appearances after cholecystectomy. CT scan of 62-year-old woman with abdominal pain and pyrexia after laparoscopic cholecystectomy shows mixed gas–fluid attenuation in gallbladder fossa, consistent with Surgicel (oxidized regenerated cellulose, Johnson & Johnson Ethicon) (arrow). Review of surgical notes confirmed that Surgicel had been used in gallbladder bed. Patient's symptoms settled without intervention.

 
Biliary dilatation may be seen postoperatively due to obstruction from retained stones or accidental clipping of bile ducts. However, after laparoscopic cholecystectomy, bile duct dilatation has also been described in the absence of obstruction [18]. Furthermore, patients with cholelithiasis may have had bile duct calculi preoperatively, and the resulting biliary dilatation may persist despite relief of the obstruction [19]. These factors should be considered when assessing the postoperative patient with dilated bile ducts, and correlation with biochemical and clinical features is important before considering further investigation.

Another potential pitfall is the use of hemostatic agents in the gallbladder bed (Fig. 1A, 1B). Surgicel (oxidized regenerated cellu lose, Johnson & Johnson Ethicon) is a bio absorbable hemostatic agent with bactericidal properties that is used in laparoscopic cholecystectomy and other surgical procedures to control hemorrhage. When imaging is performed on postoperative patients, the appearances of Surgicel can mimic those of hematoma [20], abscess [21, 22], or even tumor [23], although Surgicel can usually be differentiated from a retained surgical swab because of the radiopaque marker incorporated into the latter [24]. Failure to correctly identify Surgicel can result in patients undergoing un necessary surgery [25].


Figure 3
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  		Fig. 2 —T2-weighted MR image of 16-year-old girl with abdominal pain, elevated inflammatory markers, and pyrexia 2 months after laparoscopic cholecystectomy. Note fluid collection in gallbladder fossa (arrowhead); area of signal void anterior (arrow) to collection represents air. Patient was treated for infected collection with antibiotics, and MRI 6 months later showed resolution of changes.

 
The CT appearance of Surgicel is similar to that of an infected hematoma—that is, a mass of 40–55 HU containing foci of air [26]. Similar problems are encountered using sonography, on which the Surgicel appears as an echogenic mass with posterior reverberation artifact. These sonographic ap pearances would be accounted for by a gas-containing abscess [27]. MRI can be useful in differentiating between abscess (Fig. 2) and Surgicel because of the low signal on T2-weighted images of the latter, possibly secondary to the imaging characteristics of blood degradation products [28]. Although this might prove to be a useful problem-solving tool, good communication between surgeons and radiologists and correlation between imaging findings and the clinical history, examination, and operative findings are essential.


Figure 4
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  		Fig. 3A —Bile duct injuries. 42-year-old woman with abdominal pain, pyrexia, and leukocytosis 10 days after laparoscopic cholecystectomy. CT scan (A) shows Surgicel (oxidized regenerated cellulose, Johnson & Johnson Ethicon) in gallbladder fossa (thin arrow, A) and small fluid collection adjacent to tip of liver (thick arrow, A). Patient underwent laparotomy, which showed leak from common bile duct (CBD), which was sutured. Patient remained unwell and underwent ERCP (B), which showed persistent leak from damaged CBD (arrow, B). Leak resolved after endoscopic placement of a stent.

 


Figure 5
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  		Fig. 3B —Bile duct injuries. 42-year-old woman with abdominal pain, pyrexia, and leukocytosis 10 days after laparoscopic cholecystectomy. CT scan (A) shows Surgicel (oxidized regenerated cellulose, Johnson & Johnson Ethicon) in gallbladder fossa (thin arrow, A) and small fluid collection adjacent to tip of liver (thick arrow, A). Patient underwent laparotomy, which showed leak from common bile duct (CBD), which was sutured. Patient remained unwell and underwent ERCP (B), which showed persistent leak from damaged CBD (arrow, B). Leak resolved after endoscopic placement of a stent.

 


Figure 6
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  		Fig. 3C —Bile duct injuries. Image from ERCP in 31-year-old woman. Clips have been placed across CBD (thin arrow), and free contrast material (thick arrow) is visible because of duct injury. Patient was treated with hepatojejunostomy.

 

Biliary Complications
Top
 Abstract
 Introduction
 Normal Appearances After...
 Biliary Complications
Dropped Gallstones
 Vascular Complications
 Other Complications
 Summary
 References
 
Biliary complications are more common after laparoscopic than after open cholecystectomy [29] and include bile duct damage, biliary obstruction, and dropped stones.

Bile Duct Injury
Injury to the bile ducts often goes unrecognized at the time of surgery [30]. There should be a high level of suspicion when patients are referred with symptoms of abdom inal pain, sepsis, or jaundice soon after laparoscopic cholecystectomy [31]. The reported rate of bile duct injury after laparoscopic cholecystectomy varies among different series; however, a review of 5,913 cases over a 5-year period showed a 0.6% overall rate of bile duct injury, with the rate for individual surgeons ranging from 0.4% to 4% [9].


Figure 7
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  		Fig. 4A —56-year-old woman with abdominal pain following laparoscopic cholecystectomy. CT scan shows multiple large intraabdominal fluid collections (arrows) that contained bile when drained.

 


Figure 8
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  		Fig. 4B —56-year-old woman with abdominal pain following laparoscopic cholecystectomy. Subsequent ERCP shows leak from cystic duct stump (arrow).

 


Figure 9
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  		Fig. 4C —56-year-old woman with abdominal pain following laparoscopic cholecystectomy. Subsequent ERCP shows stent that has been deployed endoscopically in common bile duct across origin of cystic duct.

 
Initial assessment in patients with suspected bile duct injury is usually with sonography or CT [32]. These investigations may show perihepatic fluid collections (Figs. 3A, 3B, 3C and 4A, 4B, 4C), although the absence of these does not exclude injury [33]. Free intraperitoneal fluid may also be seen, although this is a nonspecific finding in a postoperative patient [34]. Hepatobiliary scintigraphy is a less commonly used non invasive method of evaluating patients with suspected bile duct injury that has two potential advantages over sonography and CT. First, it has been claimed to be more sensitive and specific than sonography or CT in detecting bile leaks [35]. Second, as well as confirming a bile leak, hepatobiliary scintigraphy may identify the relationship between the leak and the collection [36] and show the primary route of bile flow [35]. Despite this, it may be necessary to complement scintigraphy with other investigations such as ERCP to fully appreciate the degree of bile duct injury [37].

Although it is an invasive procedure, ERCP is useful in patients in whom there is a strong suspicion of bile duct injury (Fig. 3A, 3B, 3C). As well as being able to show the exact site of injury or leak, ERCP can sometimes be used to successfully treat the leak using internal stents (Fig. 4A, 4B, 4C). Success using this technique may be more likely if the injury to the duct is < 5 mm, the injury is extrahepatic, and there is no associated abscess or biloma [38]. Open surgery is the main alternative to ERCP in cases of persistent leaks; some authors have recommended ERCP as the first-line treatment for such patients in an effort to avoid the increased morbidity associated with open surgery [34].

MRCP is an alternative way of assessing the anatomy of bile ducts. The use of mangafodipir trisodium, a contrast agent that is primarily excreted via bile, makes it possible to both diagnose a bile leak and identify the source of the leak [39, 40]. The advantages of this technique are that it is noninvasive and does not use ionizing radiation; however it has limitations, including poor opacification of bile ducts in the presence of obstruction and unreliable depiction of the more peripheral intrahepatic bile ducts [39].

Biliary Obstruction
Causes of biliary obstruction include retain ed gallstones (Fig. 5A, 5B, 5C), misplaced surgical clips, fibrosis secondary to in flammation from adjacent clips, and thermal injury from cautery devices [38]. Although typically obstruction at the level of the common bile duct produces intrahepatic duct dilatation in both lobes [41], dilatation in a single lobe, most commonly the left (Fig. 6A, 6B), may also occur [42]. As discussed previously, the presence of dilated ducts alone is not diagnostic of biliary obstruction. Stones may be identified on sonography if good views of the biliary tree can be obtained or on CT if the stones are of a differing density from bile. If CT or sonography does not clearly delineate a cause for the obstruction, MRCP can identify stones as small as 2 mm that are retained in the biliary tree [43]. Identification of these stones allows planning of management strategies for patients who may require inter vention with ERCP. Alternatively, if imaging shows no obstruction or retained stones, ERCP, which is an invasive and potentially harmful investigation [44], can be avoided.


Figure 10
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  		Fig. 5A —56-year-old woman with abdominal pain 3 months after laparoscopic cholecystectomy. Axial CT image shows low-attenuation change in pancreas (arrow) and peripancreatic fluid, in keeping with pancreatitis.

 

Figure 11
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  		Fig. 5B —56-year-old woman with abdominal pain 3 months after laparoscopic cholecystectomy. MRCP shows filling defects in common bile duct (CBD) (arrows) and normal-caliber pancreatic duct (arrowheads).

 

Figure 12
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  		Fig. 5C —56-year-old woman with abdominal pain 3 months after laparoscopic cholecystectomy. ERCP confirms retained gallstones in CBD (arrow).

 

Figure 13
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  		Fig. 6A —72-year-old man with abdominal pain and abnormal liver biochemistry following laparoscopic cholecystectomy. Postoperative CT scan shows dilated ducts in left lobe of liver.

 

Figure 14
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  		Fig. 6B —72-year-old man with abdominal pain and abnormal liver biochemistry following laparoscopic cholecystectomy. ERCP shows filling defects in common bile duct that are consistent with retained stones. Gallstones were subsequently removed endoscopically.

 

Intraoperative cholangiography (IOC) can allow surgeons to identify stones in the bile ducts (Fig. 7) and also help to correctly identify the anatomy of the biliary tree, thereby preventing division of structures other than the cystic duct [45]. The role of IOC is controversial, with some surgeons advocating its use in all patients undergoing laparoscopic cholecystectomy and others reserving IOC for patients with a high risk of bile duct injury—such as patients with atypical anatomy—or retained gallstones [46]. It has been shown that, even if IOC is performed, bile duct injury may go undiagnosed at the time of surgery. In a study of 64 patients who had sustained a bile duct injury at laparoscopic cholecystectomy 39 underwent IOC. Of those 39, the injury was recognized in only 33% at the time of the operation. In retrospect, a further 29% had evidence of bile duct injury on IOC images [47]. The failure to correctly identify abnormalities on IOC has previously been highlighted as a problematic area. An editorial reviewing ways of minimizing complications of laparoscopic surgery suggested that unless a surgeon is competent at recognizing gross changes on cholangio graphy, he or she should not perform laparo scopic cholecystectomies [48]. However, as previously stated, opinion is divided, with some authors claiming there is no evidence that IOC prevents injury and is an additional burden in terms of both time and money [49].


Figure 15
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  		Fig. 7 —Intraoperative cholangiography image of 66-year-old woman shows stone at distal common bile duct (arrow) and bile duct dilatation.

 

Dropped Gallstones
Top
 Abstract
 Introduction
 Normal Appearances After...
 Biliary Complications
 Dropped Gallstones
Vascular Complications
 Other Complications
 Summary
 References
 
Spillage of gallstones occurs commonly during laparoscopic cholecystectomy, with a reported incidence of 0.1–20% [50]. Fortunately, most of these stones do not cause symptoms [46], although if spillage does occur every effort should be made to retrieve the stones in view of the small risk of developing important complications [51]. The most common complication reported in the literature is abscess, either in the abdominal wall or in the peritoneum [52]. Retained gallstones have also presented after erosion through the skin [53], as a colovesical fistula [54], with expectoration of stones (cholelithoptysis) [55], and as the cause of an incarcerated hernia [56].

Dropped gallstones leading to abscess formation can occur after a period of months to years after the laparoscopic cholecystectomy, which can make diagnosis challenging [57]. Spilled gallstones appear on sonography as small hyperechoic lesions that may be related to fluid collections and are found most often in the subdiaphragmatic or subhepatic spaces [58] (Fig. 8A, 8B). If they are calcified, gallstones may also be visible on CT as hyperdense areas or on T1-weighted MRI as a signal void [59].


Figure 16
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  		Fig. 8A —71-year-old man with history of laparoscopic cholecystectomy. Sonogram shows dropped gallstone in subdiaphragmatic space (arrow).

 

Figure 17
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  		Fig. 8B —71-year-old man with history of laparoscopic cholecystectomy. Reformatted oblique coronal CT image shows subdiaphragmatic gallstone (arrow).

 


Vascular Complications
Top
 Abstract
 Introduction
 Normal Appearances After...
 Biliary Complications
 Dropped Gallstones
 Vascular Complications
Other Complications
 Summary
 References
 
Vascular injuries during laparoscopic cholecystectomy most commonly occur in the surgical bed or the abdominal wall and are related to trocar insertion [46]. A review of 14,243 laparoscopic procedures showed an overall hemorrhage rate of 4.1%, with bleeding rates of 2.3% intraoperatively and 1.8% postoperatively [60], although the reported incidence varies among series [5, 7, 8, 10, 11].

Trocar insertion at the beginning of a laparo scopic procedure may cause bleeding because of small vessels in the abdominal wall, most commonly the inferior epi gastric vessels [61] or mesentery [62], or larger vessels such as the inferior vena cava and aorta [63]. Abdominal wall and intra peri ton eal hematomas can be readily visualized on CT as areas of higher atten uation. On sonography, hema tomas appear as heterogeneous fluid collections [64].

During the dissection of structures in the gallbladder bed, the right hepatic artery is the vessel most commonly injured, followed by the portal vein [65]. Life-threatening bleeding can occur from the gallbladder bed without obvious major vessel injury, especially in patients with preexisting liver disease such as steatosis hepatis, hepatic siderosis, and chronic or recurrent cholecystitis [66]. Hepatic artery pseudoaneurysm formation (Fig. 9A, 9B, 9C, 9D) has also been described after laparoscopic cholecystectomy and may be related to bile leak and subsequent infection [67]. If this occurs, contrast-enhanced CT may show a hematoma or directly show the pseudoaneurysm. Imaging with selective angiography of the celiac and superior mesenteric arteries is helpful in confirming the diagnosis [68] and facilitates subsequent endovascular treatment.


Figure 18
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  		Fig. 9A —41-year-old woman 3 weeks after laparoscopic cholecystectomy. Patient presented with abdominal pain. (Courtesy of R. O'Neill, Nottingham University Hospitals.) CT scans show area of hyperdensity representing contrast material (arrow) and associated area of mixed attenuation suspected to be a hematoma. This raised possibility of hemorrhage from a pseudoaneurysm. Note adjacent surgical clip (arrowhead).

 

Figure 19
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  		Fig. 9B —41-year-old woman 3 weeks after laparoscopic cholecystectomy. Patient presented with abdominal pain. (Courtesy of R. O'Neill, Nottingham University Hospitals.) CT scans show area of hyperdensity representing contrast material (arrow) and associated area of mixed attenuation suspected to be a hematoma. This raised possibility of hemorrhage from a pseudoaneurysm. Note adjacent surgical clip (arrowhead).

 

Figure 20
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  		Fig. 9C —41-year-old woman 3 weeks after laparoscopic cholecystectomy. Patient presented with abdominal pain. (Courtesy of R. O'Neill, Nottingham University Hospitals.) Diagnosis of hepatic artery pseudoaneurysm (arrow, D) was confirmed with selective angiography of celiac axis. Note adjacent surgical clip (arrowhead, D).

 

Figure 21
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  		Fig. 9D —41-year-old woman 3 weeks after laparoscopic cholecystectomy. Patient presented with abdominal pain. (Courtesy of R. O'Neill, Nottingham University Hospitals.) Diagnosis of hepatic artery pseudoaneurysm (arrow, D) was confirmed with selective angiography of celiac axis. Note adjacent surgical clip (arrowhead, D).

 

Other Complications
Top
 Abstract
 Introduction
 Normal Appearances After...
 Biliary Complications
 Dropped Gallstones
 Vascular Complications
 Other Complications
Summary
 References
 
Several less common complications of laparoscopic cholecystectomy have been reported that may be diagnosed radiologically. The incidence of port site hernia after laparoscopic surgery (Fig. 10) is estimated to be 0.02–3.6% [69] and may cause small-bowel obstruction. Although hernias are often suspected clinically because of a palpable lump at a port site, the diagnosis can be confirmed using CT [70]. Diaphragmatic hernias are more rare and can also be diagnosed with the aid of CT by revealing a defect in the diaphragm or herniation of peritoneal fat into the chest [71]. In addition, cases of portal vein thrombosis diagnosed on sonography [72], splenic rupture diagnosed on CT [73], intestinal ischemia [74], and delayed bowel perforation due to thermal injury [75] have all been reported after laparoscopic cholecystectomy.


Figure 22
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  		Fig. 10 —Axial CT image of 61-year-old woman with clinical features of small-bowel obstruction 3 days after cholecystectomy. Note fluid-filled loops of small bowel (arrowhead) proximal to hernia (arrow) at site of laparoscopy port.

 

Summary
Top
 Abstract
 Introduction
 Normal Appearances After...
 Biliary Complications
 Dropped Gallstones
 Vascular Complications
 Other Complications
 Summary
References
 
Laparoscopic cholecystectomy has an overall complication rate of approximately 3% [31]. Because of the large numbers of laparoscopic cholecystectomies being performed, it is not rare for patients to be referred for imaging investigations post operatively. In view of this, it is essential that radiologists and surgeons are aware of potential complications that may arise and their imaging appearances. Of equal importance is the recognition of normal findings after laparoscopic cholecystectomy to avoid mis interpretation. Failure to recognize these findings puts patients at risk of undergoing unnecessary and invasive procedures.


References
Top
 Abstract
 Introduction
 Normal Appearances After...
 Biliary Complications
 Dropped Gallstones
 Vascular Complications
 Other Complications
 Summary
 References
 

  1. Wu JS, Dunnegan DL, Luttmann DR, Soper NJ. The evolution and maturation of laparoscopic cholecystectomy in an academic practice. J Am Coll Surg 1998;186 : 554–560[CrossRef][Medline]
  2. Gadacz TR, Talamini MA. Traditional versus laparoscopic cholecystectomy. Am J Surg 1991;161 : 336–338[CrossRef][Medline]
  3. Kaman L, Sanyal S, Behera A, Singh R, Katariya RN. Comparison of major bile duct injuries following laparoscopic cholecystectomy and open cholecystectomy. ANZ J Surg 2006;76 : 788–791[CrossRef][Medline]
  4. Hobbs MS, Mai Q, Knuiman MW, Fletcher DR, Ridout SC. Surgeon experience and trends in intraoperative complications in laparoscopic cholecystectomy. Br J Surg 2006;93 : 844–853[CrossRef][Medline]
  5. Deziel DJ, Milikan KW, Economou SG, Doolas A, Ko ST, Airan MC. Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg1993; 165:9 –14[CrossRef][Medline]
  6. Azurin DJ, Go LS, Arroyo LR, Kirkland ML. Trocar site herniation following laparoscopic cholecystectomy and the significance of an incidental preexisting umbilical hernia. Am Surg1995; 61:718 –720[Medline]
  7. Wherry DC, Marohn MR, Malanoski MP, Hetz SP, Rich NM. An external audit of laparoscopic cholecystectomy in the steady state performed in medical treatment facilities of the Department of Defense. Ann Surg 1996; 224:145 –154[CrossRef][Medline]
  8. Shea JA, Healey MJ, Berlin JA, et al. Mortality and complications associated with laparoscopic cholecystectomy. Ann Surg1996; 224:609 –620[CrossRef][Medline]
  9. Richardson MC, Bell G, Fullarton GM, The West of Scotland Laparoscopic Cholecystectomy Audit Group. Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: an audit of 5913 cases. Br J Surg 1996;83 :1356 –1360[Medline]
  10. Z'graggen K, Wehrli H, Metzger A, Buehler M, Frei E, Klaiber C. Complications of laparoscopic cholecystectomy in Switzerland: a prospective 3-year study of 10,174 patients. Swiss Association of Laparoscopic and Thoracoscopic Surgery. Surg Endosc 1998;12 :1303 –1310[CrossRef][Medline]
  11. Hjelmqvist B. Complications of laparoscopic cholecystectomy as recorded in the Swedish laparoscopy registry. Eur J Surg Suppl 2000; (585):18 –21
  12. vanSonnenberg E, D'Agostino HB, Easter DW, et al. Complications of laparoscopic cholecystectomy: coordinated radiologic and surgical management in 21 patients. Radiology 1993;188 : 399–404[Abstract/Free Full Text]
  13. Válek V, Kala Z, Kysela P. Biliary tree and cholecyst: post surgery imaging. Eur J Radiol 2005;53 : 433–440[CrossRef][Medline]
  14. Shikare SV, Supe AN, Tilve GH. Scintigraphic detection of bile leak and follow-up in a post-cholecystectomy patient with recognition of tail sign. J Postgrad Med 1995;41 : 15–17[Medline]
  15. Lohan D, Walsh S, McLoughlin R, Murphy J. Imaging of the complications of laparoscopic cholecystectomy. Eur Radiol 2005; 15:904 –912[CrossRef][Medline]
  16. McAlister VC. Abdominal fluid collection after laparoscopic cholecystectomy. Br J Surg 2000;87 :1126 –1127[CrossRef][Medline]
  17. Moran J, Del Grosso E, Wills JS, Hagy JA, Baker R. Laparoscopic cholecystectomy: imaging of complications and normal postoperative CT appearance. Abdom Imaging 1994;19 : 143–146[CrossRef][Medline]
  18. Wedmann B, Börsch G, Coenen C, Paassen A. Effect of cholecystectomy on common bile duct diameters: a longitudinal prospective ultrasonographic study. J Clin Ultrasound1988; 16:619 –624[CrossRef][Medline]
  19. Raptopoulos V, Fabian TM, Silva W, et al. The effect of time and cholecystectomy on experimental biliary tree dilatation: a multi-imaging evaluation. Invest Radiol 1995;20 : 276–286[CrossRef]
  20. Patané F, Zingarelli E, Verzini A, di Summa M. Complication due to excessive use of Surgicel. Eur J Cardiothorac Surg 2001; 20:1034[Free Full Text]
  21. Young ST, Paulson EK, McCann RL, Baker ME. Appearance of oxidized cellulose (Surgicel) on postoperative CT scans: similarity to postoperative abscess. AJR 1993;160 : 275–277[Abstract/Free Full Text]
  22. Turley BR, Taupmann RE, Johnson PL. Postoperative abscess mimicked by Surgicel. Abdom Imaging 1994;19 : 345–346[Medline]
  23. Somani BK, Kasthuri RS, Shave RM, Emtage LA. Surgicel granuloma mimicking a renal tumor. Surgery 2006;139 : 451[CrossRef][Medline]
  24. O'Connor AR, Coakley FV, Meng MV, Eberhardt S. Imaging of retained surgical sponges in the abdomen and pelvis. AJR2003; 180:481 –489[Free Full Text]
  25. Buckley SC, Broome JC. A foreign body reaction to Surgicel mimicking an abscess or tumour recurrence. Br J Neurosurg 1995; 9:561 –563[CrossRef][Medline]
  26. Stringer MD, Dasgupta D, McClean P, Davison S, Ramsden W. "Surgicel abscess" after pediatric liver transplantation: a potential trap. Liver Transpl 2003;9 : 197–198[CrossRef][Medline]
  27. Melamed JW, Paulson EK, Kliewer MA. Sonographic appearance of oxidized cellulose (Surgicel): pitfall in the diagnosis of postoperative abscess. J Ultrasound Med 1995;14 : 27–30[Abstract]
  28. Oto A, Remer EM, O'Malley CM, Tkach JA, Gill IS. MR characteristics of oxidized cellulose (Surgicel). AJR1999; 172:1481 –1484[Abstract/Free Full Text]
  29. Khan MH, Howard TJ, Fogel EL, et al. Frequency of biliary complications after laparoscopic cholecystectomy detected by ERCP: experience at a large tertiary referral centre. Gastrointest Endosc 2007; 65:247 –252[CrossRef][Medline]
  30. Bingham J, McKie LD, McLoughlin J, Diamond T. Biliary complications associated with laparoscopic cholecystectomy: an analysis of common misconceptions. Ulster Med J 2000;69 : 106–111[Medline]
  31. Slanetz PJ, Boland GW, Mueller PR. Imaging and interventional radiology in laparoscopic injuries to the gallbladder and biliary system. Radiology 1996;201 : 595–603[Abstract/Free Full Text]
  32. Ragozzino A, De Ritis R, Mosca A, Iaccarino V, Imbriaco M. Value of MR cholangiography in patients with iatrogenic bile duct injury after cholecystectomy. AJR 2004;183 :1567 –1572[Abstract/Free Full Text]
  33. Braghetto I, Bastias J, Csendes A, Debandi A. Intraperitoneal bile collections after laparoscopic cholecystectomy. Surg Endosc 2000; 14:1037 –1041[CrossRef][Medline]
  34. Walker AT, Shapiro AW, Brooks DC, Braver JM, Tumeh SS. Bile duct disruption and biloma after laparoscopic cholecystectomy. AJR 1992; 158:785 –789[Abstract/Free Full Text]
  35. Tripathi M, Chandrashekar N, Kumar R, et al. Hepatobiliary scintigraphy: an effective tool in the management of bile leak following laparoscopic cholecystectomy. Clin Imaging2004; 28:40 –43[CrossRef][Medline]
  36. Rosenberg DJ, Brugge WR, Alavi A. Bile leak following an elective laparoscopic cholecystectomy: the role of hepatobiliary imaging in the diagnosis and management of bile leaks. J Nucl Med1991; 32:1777 –1781[Free Full Text]
  37. Trerotola SO, Savader SJ, Lund GB, et al. Biliary tract complications following laparoscopic cholecystectomy: imaging and intervention. Radiology 1992;184 : 195–200[Abstract/Free Full Text]
  38. McGahan JP, Stein M. Complications of laparoscopic cholecystectomy: imaging and intervention. AJR 1995;165 :1089 –1097[Abstract/Free Full Text]
  39. Aduna M, Larena JA, Martín D, Martínez-Guereñu B, Aguirre E, Astigarraga E. Bile duct leaks after laparoscopic cholecystectomy: value of contrast enhanced MRCP. Abdom Imaging 2005; 30:480 –487[CrossRef][Medline]
  40. Park M, Kim KW, Yu J-S, et al. Early biliary complications of laparoscopic cholecystectomy: evaluation on T2-weighted MR cholangiography in conjunction with mangafodipir trisodium–enhanced 3D T1-weighted MR cholangiography. AJR 2004;183 :1559 –1566[Abstract/Free Full Text]
  41. Teefey SA, Baron RL, Schulte SJ, Patten RM, Molloy MH. Patterns of intrahepatic bile duct dilatation: correlation with obstructive disease processes. Radiology 1992;182 : 139–142[Abstract/Free Full Text]
  42. Buxton-Thomas M, Chisholm R, Dixon AK. Intrahepatic bile duct dilatation shown by computed tomography: predilection for the left lobe? Br J Radiol 1985;58 : 499–502[Abstract/Free Full Text]
  43. Hallal AH, Amortegui JD, Jeroukhimov IM, et al. Magnetic resonance cholangiopancreatography accurately detects common bile duct stones in resolving gallstone pancreatitis. J Am Coll Surg2005; 6:869 –875
  44. Pannu HK, Fishman EK. Complications of endoscopic retrograde cholangiopancreatography: spectrum of abnormalities demonstrated with CT. RadioGraphics 2001;21 :1441 –1453[Abstract/Free Full Text]
  45. Masserweh NN, Flum DR. Role of intraoperative cholangiography in avoiding bile duct injury. J Am Coll Surg2007; 204:656 –664[CrossRef][Medline]
  46. Shamiyeh A, Wayand W. Laparoscopic cholecystectomy: early and late complications and their treatment. Langenbecks Arch Surg 2004; 389:164 –171[Medline]
  47. Slater K, Strong RW, Wall DR, Lynch SV. Iatrogenic bile duct injury: the scourge of laparoscopic cholecystectomy. ANZ J Surg 2002; 72:83 –88[CrossRef][Medline]
  48. Berci G. Complications of laparoscopic cholecystectomy. (editorial) Surg Endosc 1998;12 : 291–293[CrossRef][Medline]
  49. Wright KD, Wellwood JM. Bile duct injury during laparoscopic cholecystectomy without operative cholangiography. Br J Surg 1998; 85:191 –194[CrossRef][Medline]
  50. Brockmann JG, Kocher T, Senninger NJ, Schürmann GM. Complications due to gallstones lost during laparoscopic cholecystectomy. Surg Endosc 2002;16 :1226 –1232[CrossRef][Medline]
  51. Woodfield JR, Windsor JA. Spilled gallstones cannot be ignored. Am J Surg 2006;192 : 270–271[Medline]
  52. Zehetner J, Shamiyeh A, Wayand W. Lost gallstones in laparoscopic cholecystectomy: all possible complications. Am J Surg2007; 193:73 –78[CrossRef][Medline]
  53. Yamamuro M, Okamoto B, Owens B. Unusual presentations of spilled gallstones. Surg Endosc 2003;17 : 1498[Medline]
  54. Daoud F, Awwad ZM, Masad J. Colovesical fistula due to a lost gallstone following laparoscopic cholecystectomy: report of a case. Surg Today 2001;31 : 255–257[CrossRef][Medline]
  55. Hanna SJ, Barakat O, Watkin S. Cholelithoptysis: an unusual delayed complication of laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg 2004; 11:190 –192[Medline]
  56. Bebawi M, Wassef S, Ramcharan A, Bapat K. Incarcerated indirect inguinal hernia: a complication of spilled gallstones. JSLS 2000; 4:267 –269[Medline]
  57. McClure MJ, Mercer EE. Post laparoscopic cholecystectomy abscess: calculus or clip. Clin Radiol 2000;55 : 887–890[CrossRef][Medline]
  58. Torello Viera F, Armellini E, Rosa L, et al. Abdominal spilled stones: ultrasound findings. Abdom Imaging2006; 31:564 –567[CrossRef][Medline]
  59. Morrin MM, Kruskal JB, Hochman MG, Saldinger PF, Kane RA. Radiologic features of complications arising from dropped gallstones in laparoscopic cholecystectomy patients. AJR2000; 174:1441 –1445[Abstract/Free Full Text]
  60. Schäffer M, Lauper M, Krähenbühl L. A nation's experience of bleeding complications during laparoscopy. Am J Surg 2000; 180:73 –77[CrossRef][Medline]
  61. Geraci G, Sciumè C, Pisello F, Li Volsi F, Facella T, Modica G. Trocar-related abdominal wall bleeding in 200 patients after laparoscopic cholecystectomy: personal experience. World J Gastroenterol 2006; 12:7165 –7167[Medline]
  62. Schäffer M, Lauper M, Krähenbühl L. Trocar and Veress needle injuries during laparoscopy. Surg Endosc2001; 15:275 –280[CrossRef][Medline]
  63. Usal H, Sayad P, Hayek N, Hallak A, Huie F, Ferzli G. Major vascular injuries during laparoscopic cholecystectomy. Surg Endosc 1998; 12:960 –962[CrossRef][Medline]
  64. Ray CE Jr, Hibbeln JF, Wilbur AC. Complications after laparoscopic cholecystectomy: imaging findings. AJR1993; 160:1029 –1032[Abstract/Free Full Text]
  65. Tzovaras G, Dervenis C. Vascular injuries in laparoscopic cholecystectomy: an underestimated problem. Dig Surg2006; 23:370 –374[CrossRef][Medline]
  66. Buttenschoen K, Tsokos M, Schulz F. Laparoscopic cholecystectomy associated lethal hemorrhage. JSLS 2007;11 : 101–105[Medline]
  67. Madanur MA, Battula N, Sethi H, Deshpande R, Heaton N, Rela M. Pseudoaneurysm following laparoscopic cholecystectomy. Hepatobiliary Pancreat Dis Int 2007;6 : 294–298[Medline]
  68. Roche-Nagle G, MacEneaney P, Harte P. Pseudoaneurysm of the hepatic artery after laparoscopic cholecystectomy: a case report. J Minimal Access Surg 2006; 2:73 –75
  69. Bergemann JL, Hibbert ML, Harkins G, Narvaez J, Asato A. Omental herniation through a 3-mm umbilical trocar site: unmasking a hidden umbilical hernia. J Laparoendosc Adv Surg Tech A2001; 11:171 –173[CrossRef][Medline]
  70. Wicks A, Voyvidic F, Scroop R. Incisional hernia and small bowel obstruction following laparoscopic surgery: computed tomography diagnosis. Australas Radiol 2000;44 : 331–332[CrossRef][Medline]
  71. Armstrong PA, Miller SF, Brown GR. Diaphragmatic hernia seen as a late complication of laparoscopic cholecystectomy. Surg Endosc 1999; 13:817 –818[CrossRef][Medline]
  72. Preventza OA, Habib FA, Young SC, Penney D, Oppat W, Mittal VK. Portal vein thrombosis: an unusual complication of laparoscopic cholecystectomy. JSLS 2005;9 : 87–90[Medline]
  73. Leff D, Nortley M, Melly L, Bhutiani RP. Ruptured spleen following laparoscopic cholecystectomy. JSLS 2007;11 : 157–160[Medline]
  74. Leduc L, Mitchell A. Intestinal ischemia after laparoscopic cholecystectomy. JSLS 2006;10 : 236–238[Medline]
  75. Polychronidis A, Tsaroucha AK, Karayiannakis AJ, Perente S, Efstathiou E, Simopoulos C. Delayed perforation of the large bowel due to a thermal injury during laparoscopic cholecystectomy. J Int Med Res 2005; 33:360 –363[Medline]

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