- Expected postsurgical findings
- Biliary Tract Related Complications
- Gallbladder related complications
- Other Complications
If the cholecystectomy has been complete, we will observe a complete absence of the gallbladder and the presence of two or more clippers ligating the duct and cystic artery. Postsurgical edema in the gallbladder fossa is a normal finding in the first week after surgery, manifested as fat stranding and minimal fluid bounded to the gallbladder fossa. When hemostatic agents are applied to the surgical bed, they appear as gas bubbles and mimic a fluid collection or a retained surgical sponge. Other findings include a small pneumoperitoneum and ill-defined areas of fluid from the placement of a laparoscopic port.[fig3] (fig4) (fig5)
We are going to review the complications that are related to or are most commonly found in the laparoscopic procedure, organising them into four main groups: biliary complications, vascular injuries and bleeding complications, stone-related complications, gallbladder complications and other complications (fig6). The most important risk factors with which these complications are associated are shown in (Fig7)].
2.1 Biliary injuries
Biliary injuries are the most common complications after laparoscopic cholecystectomy. The predominant causes are accidental cutting of bile ducts, unintentionally placed clips, and thermal injury due to electrocautery. Biliary injuries can lead to either bile leak or obstruction because of stricture formation due to periductal fibrosis.
The most common surgically important variants associated with this type of injury are: the right posterior hepatic duct draining into the common hepatic duct or into the cystic duct, and a subvesical bile duct (previously termed the duct of Luschka) that is prone to injury because of its close proximity to the surgical field. Also, common variants of the cystic that increase the risk for injury are a low insertion of the cystic duct, a long parallel course of the cystic duct to the common hepatic duct, and a short cystic duct. [fig8] [fig9]
A classification of biliary injuries is outlined in the figures :[fig10] [fig11]
2.1.1Bile Leaks and Bilomas
Major biliary leakage is usually seen 2-10 days postcholecystectomy. If a bile leak is contained as a collection of fluid, it is called biloma that is usually located near the site of injury, in the gallbladder fossa or in perihepatic/subcapsular spaces.
In imaging techniques, a biloma is a simple or loculated fluid collection with an enhancing wall. A bile leak often appears with a small to moderate amount of perihepatic fluid, generally accumulating around the right perihepatic space and into the right paracolic gutter. Magnetic resonance cholangiopancreatography (MRCP) allows accurate anatomic evaluation of the fluid-filled bile ducts, and the addition of gadoxetate-enhanced sequences can provide direct evidence of a leak. [fig12 ][fig13] [fig14]
Large loculated collections may need to be drained to prevent infection. Percutaneous transhepatic cholangiography, or endoscopic retrograde cholangiopancreatography (ERCP) is then usually performed to define the anatomy of the leak. Leaks may also be treated during ERCP with biliary stenting, and extensive injuries may require surgical intervention, such as Roux-en-Y hepaticojejunostomy. [fig15] [fig16]
2.1.2 Acute Biliary ObstructionBiliary injuries near the common bile duct or the confluence of hepatic ducts may acutely obstruct the biliary tree. Patients may present with jaundice, pruritis, or ascending cholangitis. At imaging techniques, we are going to observe segmental or diffuse intrahepatic biliary duct dilatation. CT allows identification of the location of metallic clips and MRI provides excellent anatomical information of the biliary anatomy proximal and distal to the level of injury. [fig17] [fig18]
2.1.3 Biliary Stricture
Biliary strictures are a rare delayed complication of laparoscopic cholecystectomy and develop because of fibrosis adjacent to surgical clips, after direct injury, or after thermal injury during dissection. Like acute injuries, variant biliary anatomy is a risk factor. [fig19]
Unrecognised and untreated central biliary strictures can result in secondary biliary cirrhosis. Similarly, segmental strictures may result in the atrophy of a portion of the liver. Some of these injuries can be conservatively managed, whereas others may require liver resection or biliary drainage.
3. Bleeding complications and vascular injury
3.1 Bleeding complications
Bleeding from laparoscopic cholecystectomy can occur from the liver bed or blood vessels due to injury to the middle hepatic vein, the right hepatic or cystic artery, being less frequent secondary to portal injury. Also, trocar sites can bleed due to injury to branches of inferior epigastric vessels.
The diagnosis of hematoma can be made by visualisation of higher attenuation collections in the area where bleeding occurs and active bleeding as contrast leaks on CT. If the patient is hemodynamically unstable, direct evaluation by re-laparoscopy is recommended.[fig20] [fig21]
3.2 Vascular Injury
A vascular injury can lead to liver infarction in about 10 percent of patients. The right hepatic artery is most often injured due to its proximity to the bile duct. Injuries involving the portal vein or common or proper hepatic arteries are less common but have more serious effects, including rapid infarction of the liver, requiring urgent right hepatectomy or a liver transplant. On CT, infarction presents as an ill-defined wedge-shaped area of hypoattenuation that is mostly peripheral, and later it manifests as liver atrophy.
Cystic or hepatic artery pseudoaneurysm formation has also been described after laparoscopic cholecystectomy, related to local inflammation or direct injury to the arterial wall. On CT, pseudoaneurysm is seen as a rounded mass in the porta hepatis that enhances avidly during the arterial phase and follows the blood pool in later phases. Treatment usually involves arterial embolisation or surgical ligation.
4. Stone-related complications4.1 Retained or recurrent calculi
Calculi are classified as retained or recurrent if found before or after 2 years following surgery, respectively. Retained stones are stones that are unrecognised during surgery, whereas recurrent stones develop in the extrahepatic biliary system after surgery. [fig22] [fig23]The most common locations for retained or recurrent stones are the remnant gallbladder, the cystic duct, and the common bile duct. If the stone grows in the cystic duct, it may cause a mass effect on the common bile duct, known as Mirizzi syndrome.
Calculi appear as filling defects within the bile duct, usually in the dependent position, surrounded by a thin rim of hyperintense bile, on MRCP.
4.2 Dropped Gallstones
Gallbladder perforation and consequent gallstone spillage into the peritoneum is a relatively common complication and occur in up to 40% of laparoscopic cholecystectomies. Complications may occur soon or may manifest months or years after surgery. The most common complication is formation of an abscess, which is classically found in the hepatorenal space. [fig24]
On CT, calcified stones may appear as one or multiple hyperdense foci in hepatorenal space, the gallbladder fossa and the pelvis. MRI can be helpful, with stones showing hypointensity T1 and T2-weighted sequences that do not show enhancement with contrast. Cholesterol or pigmented stones may be more difficult to appreciate on CT.
Subtotal or partial cholecystectomy is considered a safe procedure in complicated cases with difficult dissection and dense adhesions in the calot's triangle due to the inflammatory process. On imaging, residual fluid-filled structure in the region of the gallbladder fossa with wall formation by the omentum is seen with or without stones. Recurrent symptomatic cholelithiasis or cholecystitis is one of the risks of a subtotal cholecystectomy. A complete cholecystectomy should be performed as treatment. [fig25]
Other complications that can be encountered in post-laparoscopic cholecystectomy are biliary-enteric fistulas, duodenal perforation, clip migration, cystic duct stump mucocele, neuroma and suture granuloma, sphincter of Oddi dysfunction, incisional hernia at the port sites and among others. [fig26] [fig27]