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Postlaparoscopic cholecystectomy pelvic gallstones associated with chronic pain
May 2000, Vol. 7, No. 2
The journal of the American Association of Gynecologic Laparoscopists
Postlaparoscopic Cholecystectomy Pelvic Gallstones Associated with Chronic Pain Georgine Lamvu-Schooler, M,D., and John F. Steege, M.D.
Abstract A 23-year-old gravida 1, para 1 woman experienced chronic pelvic pain and cul-de-sac nodularity starting 1 year after laparoscopic cholecystectomy. Repeat laparoscopy revealed numerous clusters of gallstones that were removed, resulting in resolution of her symptoms. Gallstones should be included in the differential diagnosis of the symptomatic patient with a history of cholecystectomy, and surgical records should be carefully reviewed for spillage of stones. It is feasible to remove gallstones laparoscopically. (J Am Assoc Gynecol Laparosc 7(2):273-275, 2000)
Laparoscopic cholecystectomy has been heralded as one of the most important advances in laparoscopic surgery. Compared with cholecystectomy by laparotomy, patients have less postoperative pain and shorter hospital stay. Although complications from this technique are rare, they do carry substantial morbidity when they occur. They include common bile duct injury (0.5-0.25%), bleeding (0.35%), bile leakage (0.35%), and injury to surrounding organs (0.140.25 %). Spillage of gallstones from gallbladder peflbration occurs in a significant number of cases (20-30%) and can lead to intraperitoneal abcess and fistula formation. ~~' Reports in the gynecologic literature implicate spilled gallstones in chronic pelvic pain, dyspareunia, infertility, and dysmenorrhea. <7 9 Our patient experienced pelvic pain and dyspareunia. These cases raise important questions about the reproductive impact of gallstones spilled at the time of laparoscopic cholecystectomy.
denied fevers, chills, nausea, vomiting, or urinary tract symptoms. The pain was initially mild and intermittent, but gradually increased in intensity and duration to the point of being severe, sharp, cramping, and present daily. It eventually became continuous and was not related to her menstrual cycles. She had undergone laparoscopic cholecystectomy 1 year before the onset of symptoms. Pelvic examination revealed some right lower quadrant tenderness and right adnexal fullness; pelvic ultrasound was nondiagnostic. The woman's pain failed to resolve with medical management including nonsteroidal antiinflammatory drugs, narcotics, antibiotics, oral contraceptives, and depot leuprolide injections. Physical examination 6 months later revealed posterior cul-de-sac nodularity. Diagnostic laparoscopy performed by the gynecologist revealed numerous yellow lesions along both uterosacral ligaments, posterior and anterior cul-desacs, uterus, and rectosigmoid colon. Review of medical records revealed that stone spillage had occurred during laparoscopic cholecystectomy, but no immediate morbidity was apparent. The woman was referred 18 months after cholecystectomy. Physical examination was remarkable for diffuse pelvic tenderness and nodularity. Repeat
Case Report A 23-year-old gravida 1, para 1 woman saw her gynecologist with complaints of pelvic pain, constipation, and dyspareunia that started 1 year earlier. She
From the Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina (both authors). Address reprint requests to John E Steege, M.D., Department of Obstetrics and Gynecology, University of North Carolina, CB 7570, MacNider Building, Chapel Hill, NC 27599-7570; fax 919 966 5833. Accepted for publication January 3 i, 2000.
273
Posflaparoscopic Chdecystectomy Pelvic Gallstones LamvuSchoder and Steege
laparoscopy was performed through 5-mm ports in the right and left lower quadrants and 1 l-mm ports in the umbilical and suprapubic areas. Many clusters of gallstones were present throughout the pelvis (Figure 1), with adhesions surrounding the stones and partially occluding anterior and posterior cul-de-sacs. There was no evidence of endometriosis or other lesions that could account for the patient's pain. The gallstones were removed by irrigation and sharp or blunt dissection. Areas of dissection were heavily inigated, smaller stones suctioned out, and larger stones removed in an endoscopic bag. Removal of posterior cul-de-sac stones required resection of approximately 10 cm 2 of peritoneum. The surgery was uncomplicated and lasted approximately 2.5 hours. Pathologic examination confirmed gallstones and bile pigment surrounded by inflammatory cells. The patient's postoperative course was uncomplicated. Four weeks later she reported greater than 95% resolution of pain. Pelvic examination revealed no tenderness or nodularity, and a year later she continued to be pain-free. Discussion
Since its introduction, laparoscopic cholecystectomy has become the preferred surgical treatment for many patients with symptomatic gallstones. Complications occur in 2% to 5% of cases, however, with gallbladder perforation rates as high as 30%. 2 Injury can occur during dissection of the gallbladder bed, while
extracting gallbladder from the abdomen, or after slippage of cystic duct clips on the gallbladder side. 2 Methods of gallstone removal include placing the gallbladder inside an endoscopic bag at dissection, removing individual stones with forceps or a suction device, or placing them in an intraperitoneal bag.m Initially, spilled gallstones were believed to be of little consequence; however, case reports described intraabdominal abscess and fistula and granuloma formation after gallstone spillage. 2'3'tt Gallstones were found in the pelvis of a 28-yearold woman who reported dysmenorrhea that began after laparoscopic cholecystectomy.7 Her pain resolved after the gallstones were removed laparoscopically. Gallstones implanted on the ovaries and pelvic peritoneum were associated with dysmenorrhea, infertility, and chronic pelvic pain in two other patients. 4,9 In a woman with dyspareunia and chronic pelvic pain, laparoscopy revealed a mass that consisted of approximately 40 gallstones, t2 These cases and our patient raise several concerns not previously emphasized. It would appear that gallstones, especially when present in large numbers, can cause a chronic inflammatory response and become embedded in pelvic peritoneum. Removing these embedded stones is challenging and tedious, but is quite feasible laparoscopically. Clinical evaluation of chronic pelvic pain should include queries about surgeries such as cholecystectomy, and old operative records should be carefully reviewed. Finally, it would appear worth while to follow prospectively the reproductive histories and pelvic complaints of women in whom spillage of gallstones occurs during laparoscopic cholecystectomy. Such a study might help surgeons decide how aggressively to manage the stones and help gynecologists to interpret pelvic symptoms in such patients. References
1. Nyhus L, Baker R, Fischer JE: Mastery of Surgery, 3rd ed. Boston, Little, Brown, 1997, p 1098 2. Kimura T, Goto H, Takeuctii Y, et al: intraabdominal contamination after gallbladder perforation during laparoscopic cholecystectomy and its implications. Surg Endosc 10:888-891, 1996 3. Rasmussen I, Lundren E, Osterberg J, et al: Spilled gallstones: A complication of laparoscopic cholecystectomy. Eur J Surg 163:147-150, 1997
FIGURE 1. Numerous clusters of gallstones implanted in the left ovarian fossa and posterior cul-de-sac.
274
May 2000, Vd 7, No, 2
The Journal of the American Association oF Gynecologic laparoscopists
8. Dulernba JF: Spilled gallstones causing pelvic pain. J Am Assoc Gynecol Laparosc 3:309-311, 1996
4. Vadlamudi G, Graebe R, Khoo M, et al: Gallstones implanting in the ovary: A complication of laparoscopic cholecystectomy. Arch Pathol Lab Med 121 : 155-158, 1997
9. Pfeifer ME, Hansen KA, Tho SP, et al: Ovarian cholelithiasis after laparoscopic cholecystectomy associated with chronic pelvic pain. Fertil Steril 66: 1031-1032, 1996
5. Larson GM, Vitale GC, Casey J, et al: Multipractice analysis of laparoscopic cholecystectomy in 1,983 patients. Am J Surg 163:221-226, 1992
10. Paramesh A, Casale T, Peralta R, et al: Tandem subdiaphragmatic and pleural sequelae due to lost gallstones after cholecystectomy. J Soc Laparosc Surg 2:285-288, 1998
6. Deziel DL Millikan KW, Economou SG, et al: Complications of laparoscopic cholecystectomy: A national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg 165:9-14, 1993
11. Bonar JR Bowyer MW, Welling DR, et al: The fate of retained gallstones after laparoscopic cholecystecomy in prairie dog model. J Soc Laparosc Surg 2:263-268, 1998
7. Stevens GH, Debets JM, Wilig AR et al: Dysmenorrhea related to gallstone spilling after laparoscopic cholecystectomy. Eur J Obstet Gynecol Reprod Biol 67: 63-64, 1996
12. Robbins M: Gallstones presenting as a cul-de-sac mass. Obstet Gynecol 91:842-843, 1998
275
The journal of the American Association of Gynecologic Laparoscopists
Postlaparoscopic Cholecystectomy Pelvic Gallstones Associated with Chronic Pain Georgine Lamvu-Schooler, M,D., and John F. Steege, M.D.
Abstract A 23-year-old gravida 1, para 1 woman experienced chronic pelvic pain and cul-de-sac nodularity starting 1 year after laparoscopic cholecystectomy. Repeat laparoscopy revealed numerous clusters of gallstones that were removed, resulting in resolution of her symptoms. Gallstones should be included in the differential diagnosis of the symptomatic patient with a history of cholecystectomy, and surgical records should be carefully reviewed for spillage of stones. It is feasible to remove gallstones laparoscopically. (J Am Assoc Gynecol Laparosc 7(2):273-275, 2000)
Laparoscopic cholecystectomy has been heralded as one of the most important advances in laparoscopic surgery. Compared with cholecystectomy by laparotomy, patients have less postoperative pain and shorter hospital stay. Although complications from this technique are rare, they do carry substantial morbidity when they occur. They include common bile duct injury (0.5-0.25%), bleeding (0.35%), bile leakage (0.35%), and injury to surrounding organs (0.140.25 %). Spillage of gallstones from gallbladder peflbration occurs in a significant number of cases (20-30%) and can lead to intraperitoneal abcess and fistula formation. ~~' Reports in the gynecologic literature implicate spilled gallstones in chronic pelvic pain, dyspareunia, infertility, and dysmenorrhea. <7 9 Our patient experienced pelvic pain and dyspareunia. These cases raise important questions about the reproductive impact of gallstones spilled at the time of laparoscopic cholecystectomy.
denied fevers, chills, nausea, vomiting, or urinary tract symptoms. The pain was initially mild and intermittent, but gradually increased in intensity and duration to the point of being severe, sharp, cramping, and present daily. It eventually became continuous and was not related to her menstrual cycles. She had undergone laparoscopic cholecystectomy 1 year before the onset of symptoms. Pelvic examination revealed some right lower quadrant tenderness and right adnexal fullness; pelvic ultrasound was nondiagnostic. The woman's pain failed to resolve with medical management including nonsteroidal antiinflammatory drugs, narcotics, antibiotics, oral contraceptives, and depot leuprolide injections. Physical examination 6 months later revealed posterior cul-de-sac nodularity. Diagnostic laparoscopy performed by the gynecologist revealed numerous yellow lesions along both uterosacral ligaments, posterior and anterior cul-desacs, uterus, and rectosigmoid colon. Review of medical records revealed that stone spillage had occurred during laparoscopic cholecystectomy, but no immediate morbidity was apparent. The woman was referred 18 months after cholecystectomy. Physical examination was remarkable for diffuse pelvic tenderness and nodularity. Repeat
Case Report A 23-year-old gravida 1, para 1 woman saw her gynecologist with complaints of pelvic pain, constipation, and dyspareunia that started 1 year earlier. She
From the Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina (both authors). Address reprint requests to John E Steege, M.D., Department of Obstetrics and Gynecology, University of North Carolina, CB 7570, MacNider Building, Chapel Hill, NC 27599-7570; fax 919 966 5833. Accepted for publication January 3 i, 2000.
273
Posflaparoscopic Chdecystectomy Pelvic Gallstones LamvuSchoder and Steege
laparoscopy was performed through 5-mm ports in the right and left lower quadrants and 1 l-mm ports in the umbilical and suprapubic areas. Many clusters of gallstones were present throughout the pelvis (Figure 1), with adhesions surrounding the stones and partially occluding anterior and posterior cul-de-sacs. There was no evidence of endometriosis or other lesions that could account for the patient's pain. The gallstones were removed by irrigation and sharp or blunt dissection. Areas of dissection were heavily inigated, smaller stones suctioned out, and larger stones removed in an endoscopic bag. Removal of posterior cul-de-sac stones required resection of approximately 10 cm 2 of peritoneum. The surgery was uncomplicated and lasted approximately 2.5 hours. Pathologic examination confirmed gallstones and bile pigment surrounded by inflammatory cells. The patient's postoperative course was uncomplicated. Four weeks later she reported greater than 95% resolution of pain. Pelvic examination revealed no tenderness or nodularity, and a year later she continued to be pain-free. Discussion
Since its introduction, laparoscopic cholecystectomy has become the preferred surgical treatment for many patients with symptomatic gallstones. Complications occur in 2% to 5% of cases, however, with gallbladder perforation rates as high as 30%. 2 Injury can occur during dissection of the gallbladder bed, while
extracting gallbladder from the abdomen, or after slippage of cystic duct clips on the gallbladder side. 2 Methods of gallstone removal include placing the gallbladder inside an endoscopic bag at dissection, removing individual stones with forceps or a suction device, or placing them in an intraperitoneal bag.m Initially, spilled gallstones were believed to be of little consequence; however, case reports described intraabdominal abscess and fistula and granuloma formation after gallstone spillage. 2'3'tt Gallstones were found in the pelvis of a 28-yearold woman who reported dysmenorrhea that began after laparoscopic cholecystectomy.7 Her pain resolved after the gallstones were removed laparoscopically. Gallstones implanted on the ovaries and pelvic peritoneum were associated with dysmenorrhea, infertility, and chronic pelvic pain in two other patients. 4,9 In a woman with dyspareunia and chronic pelvic pain, laparoscopy revealed a mass that consisted of approximately 40 gallstones, t2 These cases and our patient raise several concerns not previously emphasized. It would appear that gallstones, especially when present in large numbers, can cause a chronic inflammatory response and become embedded in pelvic peritoneum. Removing these embedded stones is challenging and tedious, but is quite feasible laparoscopically. Clinical evaluation of chronic pelvic pain should include queries about surgeries such as cholecystectomy, and old operative records should be carefully reviewed. Finally, it would appear worth while to follow prospectively the reproductive histories and pelvic complaints of women in whom spillage of gallstones occurs during laparoscopic cholecystectomy. Such a study might help surgeons decide how aggressively to manage the stones and help gynecologists to interpret pelvic symptoms in such patients. References
1. Nyhus L, Baker R, Fischer JE: Mastery of Surgery, 3rd ed. Boston, Little, Brown, 1997, p 1098 2. Kimura T, Goto H, Takeuctii Y, et al: intraabdominal contamination after gallbladder perforation during laparoscopic cholecystectomy and its implications. Surg Endosc 10:888-891, 1996 3. Rasmussen I, Lundren E, Osterberg J, et al: Spilled gallstones: A complication of laparoscopic cholecystectomy. Eur J Surg 163:147-150, 1997
FIGURE 1. Numerous clusters of gallstones implanted in the left ovarian fossa and posterior cul-de-sac.
274
May 2000, Vd 7, No, 2
The Journal of the American Association oF Gynecologic laparoscopists
8. Dulernba JF: Spilled gallstones causing pelvic pain. J Am Assoc Gynecol Laparosc 3:309-311, 1996
4. Vadlamudi G, Graebe R, Khoo M, et al: Gallstones implanting in the ovary: A complication of laparoscopic cholecystectomy. Arch Pathol Lab Med 121 : 155-158, 1997
9. Pfeifer ME, Hansen KA, Tho SP, et al: Ovarian cholelithiasis after laparoscopic cholecystectomy associated with chronic pelvic pain. Fertil Steril 66: 1031-1032, 1996
5. Larson GM, Vitale GC, Casey J, et al: Multipractice analysis of laparoscopic cholecystectomy in 1,983 patients. Am J Surg 163:221-226, 1992
10. Paramesh A, Casale T, Peralta R, et al: Tandem subdiaphragmatic and pleural sequelae due to lost gallstones after cholecystectomy. J Soc Laparosc Surg 2:285-288, 1998
6. Deziel DL Millikan KW, Economou SG, et al: Complications of laparoscopic cholecystectomy: A national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg 165:9-14, 1993
11. Bonar JR Bowyer MW, Welling DR, et al: The fate of retained gallstones after laparoscopic cholecystecomy in prairie dog model. J Soc Laparosc Surg 2:263-268, 1998
7. Stevens GH, Debets JM, Wilig AR et al: Dysmenorrhea related to gallstone spilling after laparoscopic cholecystectomy. Eur J Obstet Gynecol Reprod Biol 67: 63-64, 1996
12. Robbins M: Gallstones presenting as a cul-de-sac mass. Obstet Gynecol 91:842-843, 1998
275