laparoscopy ppt

1. Stump stone after
cholecystectomy
DR. HIWA OMER AHMED
PROFESSOR IN GENERAL AND BARIATRIC SURGERY
UNIVERSITY OF SULAIMANI
COLLEGE OF MEDICINE – SULAIMANI CITY- KURDISTAN

2. Postcholecystectomy syndrome
 The recurrence of symptoms similar to those before the procedure of cholecystectomy is called
postcholecystectomy syndrome.
 It occurs in 10–40% of patients anywhere between 2 days and 25 years.
 The causes include
1. Strictures
2. Retained calculi
3. Dropped calculi
4. Tumours
5. Sphincter of Oddi dysfunction
6. Calculi in the cystic duct remnant.

3. Cystic duct stones
 Calculi in the cystic duct remnant are one of the causes of postcholecystectomy
syndrome.
 The incidence of cystic duct remnant stone after cholecystectomy is less than
2.5%.
 Very few case reports and series have been published on this stump stone.
 Most of the patients presented less than 2 years after cholecystectomy,

4. Type of intervention
 A stump longer than 1 cm is called a cystic duct remnant.
 It is more common after laparoscopic cholecystectomy than open because in open surgery
the cystic duct is ligated and cut as close to the common bile duct as possible, whereas in
laparoscopic cholecystectomy, it is cut closer to the gallbladder to avoid iatrogenic injury
to the common bile duct, leaving a longer remnant.
 This is of paramount importance to avoid iatrogenic injury to the common bile duct.
However, this renders the possibility of leaving a long cystic duct remnant

5. Anatomical variations
 The anatomy of the cystic duct is highly variable from one patient to another.
It is sometimes very short and falls directly into the CBD; at other times, it is
very long and passes behind or parallel to the CBD, entering it only a few
millimeters above its termination.

6. Incidence
 less than 2.5%.
 In 1912, Florcken described the first case of a cystic duct remnant
containing stones.
 Rogy et al found only 8 who had a stone in the cystic duct or gallbladder
remnant in a series of 322 patients.
 Zhou et al found 4 who had a stone in the cystic duct remnant in a series
of 371 patients.
 It is a rare, suspicion is required to make the diagnosis.

7. Diagnosis
 Cystic duct remnant stones are difficult to diagnose.
 Ultrasonography may occasionally suggest cystic duct stones by
showing an acoustic shadow.
 ERCP correctly diagnosed the retained stone in most patients;
 The accuracy of MRCP in detecting cystic duct remnant stones is
difficult.

8. MRCP image of post-cholecystectomy GB
remnant

9. A. ERCP with basket is the first line of treatment for stump
stones.
 Limitations
1. the proximal position of the stone in the cystic duct,
2. stone impaction
3. the smaller diameter of the cystic duct.

10. B. Extracorporeal shock-wave lithotripsy (ESWL) with fragmentation of
stones and basketting them out,
C. Endoscopic biliary laser lithotripsy
D. Repeat laparoscopic cholecystectomy
 The cystic duct remnant and the Calot triangle are surrounded by
inflamed scar tissue, after incomplete cholecystectomy, which makes
laparoscopic reoperation difficult.
 repeat cholecystectomy is safe and feasible laparoscopically.

11. Cystic duct stump with clips in situ

12. Removal of stone using a blunt grasper.

13. Stone retrieved from a cystic duct stump.

14. Closure of stump with 2–0 vicryl.

15. GB remnant