Gallbladder perforation with spillage of bile and gallstones is not uncommon during laparoscopic cholecystectomy, with an incidence reported at 16% [1]. Missed spilled stones can lead to complications, as reported in up to 19% as an intraabdominal abscess, persistent port site discharge, bowel obstruction, fistula, etc., many months after the uneventful laparoscopic cholecystectomy [2]. Stone spillage can happen during gallbladder dissection of the liver bed, causing accidental wall perforation or injury with the grasping forceps, leading to intraperitoneal dislodgement [3]. Patients with acute cholecystitis, advanced age, male sex, spillage of more than 15 stones with a diameter of at least 1.5 cm, pigment stones, and perihepatic localization are some indicators that complications may occur in the future [4]. Surgeons are often reluctant to document or inform the patient regarding intraoperative and unretrieved stone spillage [5]. We report a case of missed spilled stones during laparoscopic cholecystectomy, causing recurrent discharging sinuses on the back for 9 painful years, along with a literature review.

A 44-year-old female was admitted to the surgery department to assess the cause of recurrent discharging sinuses on the right back for 9 years (Fig. 1). She had undergone laparoscopic cholecystectomy elsewhere for gallstones in 2009 with an uneventful postoperative recovery, as recorded in the discharge sheet. She developed a spontaneous onset painful discharging sinus from her right back in 2013. The sinus tract excision was done in 2013 by the same surgeon and put on antitubercular drugs empirically as tuberculosis is prevalent in India. The patient was asymptomatic for 5 years until she developed multiple discharging sinuses in the same area in 2018 and underwent repeated surgeries. The patient remained asymptomatic for another 2 years till it recurred. We attended the patient in 2021 and evaluated her with a computed tomography (CT) sinogram which revealed a curvilinear tract in the right lumbar region (5.8 cm length, 9 mm thickness) extending into the right subpleural space (Fig. 2).

Figure 1. Scar from previous surgeries on the right back with persistent sinus opening with pus discharge (arrow).

Figure 2. The computed tomography sinograms showing sinus tract (arrows) extending into the right subpleural space.

The patient was positioned in the left lateral position. We used methylene blue dye for better delineation of the sinus tract. A probe was inserted to help guide the dissection. We cut through the external oblique, internal oblique, and transverse abdominis muscles, as the tract went through them. The tract went diagonally upward through the 10th and 11th ribs which were cut for better visualisation. The tract led to a closed space on the right, just below the pleura, filled with pus and gallstones (Fig. 3, 4). We excised the tract completely and sent it for histopathological examination. We thoroughly washed the cavity with normal saline to remove leftover stones, and a drain was placed.

Figure 3. Intraoperative photograph depicting gallstones (arrow) present in the sinus cavity.

Figure 4. Multiple retrieved gallstones from the sinus cavity.

The patient was discharged on the 5th postoperative day with a healthy wound. The patient had a smooth postoperative recovery, and the histopathological report was nonspecific. After 1 year of sinus tract excision, there is no clinical or radiological recurrence.

Gallbladder perforations during laparoscopic cholecystectomy can occur between 10% and 40% of the time, while stone spillage reported to occur in 5.7%. Nonetheless, spillage-related problems are uncommon. In a report on 10,174 patients, 581 (5.7%) had stones spilled, and just 34 had them recovered. Only eight patients (0.08%) of the remaining 547 participants experienced problems [6].

During laparoscopic cholecystectomy, stone spillage occurs frequently, but the incidence is underreported. Papasavas et al. [1] identified the same complication in 127 laparoscopic cholecystectomy cases but just two stone-spillage occurrences in open cholecystectomy in their literature review. Still, retrieving the spilled stones that may migrate to the subphrenic or deep into the hepatorenal pouch is often difficult. This is unquestionably connected to how challenging laparoscopic procedures are compared to open ones for retrieving dropped stones.

The majority of cases of stone spillage remain asymptomatic; therefore, incidental finding in the absence of problems does not warrant a laparotomy [7].

If gall bladder perforation occurs inadvertently during the dissection, the surgeon should suck the spilled bile and meticulously retrieve the stones into an endo bag to avoid missing them in the less accessible spaces. If possible, the rent in the gallbladder should be grasped either by forceps or an endoclip applied to it. After removing the gallbladder, one should thoroughly irrigate the gallbladder bed with normal saline, avoiding spilled gallstones from migrating to difficult accessible sites. One should make all reasonable efforts to remove the spilled gallstones; nevertheless, conversion to open surgery is not mandatory as the reported complication rate out of lost stones is less than 1% [7].

Moreover, Mullerat et al. [5] discovered that just one-fifth of the surgeons listed gallstone spillage as a potential risk on the consent form. Also, if this happens during surgery, they seldom mention it to the patient or in the operation notes. As a result, any complications arising from it will cause a diagnostic dilemma for the future attending clinician.

In their systematic review, Gavriilidis et al. [8] reported pain, fever, nausea, vomiting, abdominal distension, fistula formation, and weight loss as the most common presenting symptoms in retained spilled stones following laparoscopic cholecystectomy. The most frequent complication was abscess formation in up to 56.5%, located either intrabdominal (36.5%), abdominal wall (10.6%), or retroperitoneum (9.4%). Interestingly, 12% of patients were managed with ultrasonography and CT scan-guided drainage, and 87% underwent surgery for the complications; the other two cases were incidentally diagnosed and scheduled for routine follow-ups. On the 11th postoperative day, one patient died following lung decortication for thoracic empyema caused by lost spilled gallstones [8]. Even the diagnosis of such a case is usually tricky because of the unusual clinical manifestations, radiologically occult nature, diverse locations, clinician’s ignorance of the condition, and the lack of specific information about the spilled stones in the operation notes.

The significant delay in presentation also complicates the issue, as the patient may have reached the age group where malignancies are more likely thought of as the cause, especially if the records about the spill are missing. Furthermore, there is a chance of misdiagnosis since the imaging characteristics of spilled stones may resemble those of peritoneal metastases, peritoneal loose bodies, lymph nodes, colonic diverticula, or dropped appendicoliths [9]. Such situations burden the economy with an extensive workup for malignancy, resulting in significant physical and psychological trauma to the patient [9].

The surgeon must inform the patient and document spilled gallstones in the surgical records. That will help during subsequent clinical encounters and hospital admissions out of complications following left-out spilled stones. Moreover, there is a need to appraise surgeons’ awareness of spilled gallstones so that practicing and training surgeons feel obligated to take preventative steps and, over time, develop standardized practices.

Ethical statements

Institutional Review Board of All India Institute of Medical Sciences approved the publication of this case report (No. AIIMS/BBSR/SURGERY/2023/263). Informed written consent was obtained from the patient for publication of the report and accompanying images.

Authors’ contributions

Conceptualization, Data curation, Formal analysis: All authors

Writing–original draf: All authors

Writing–review & editing: All authors

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding/support

None.

Data availability

The data presented in this study are available upon reasonable request to the corresponding author.