36 Retro-hepatic abscess as a complication following laparoscopic cholecystectomy

Abstract Laparoscopic cholecystectomy is a common, safe and effective procedure as a surgical solution of gallbladder stones. Throughout multiple studies, it has proven as a procedure with a generally low frequency of associated complications, varying from 0,5% to 6%, from which 13% of the complications were intraoperative, spilling of the gallbladder stones represented only an approximate 2% of intraoperative complications. The authors report a rare case of a 41-year-old female patient with fever and elevated inflammatory markers, leading to a diagnosis of retro-hepatic abscess of the right hepatic lobe. The patient was suffering from fever, fatigue and chronic abdominal pain in right hypochondrium. She was treated by a general practitioner by empiric oral antibiotics, however septic signs remained. Due to her recent travel history, she was examined by a infectious disease specialist. She underwent a series of diagnostics, including an ultrasound, which has shown an abscess-like formation with calcifications, sized approximately 9 × 8 × 7 cm, suspected as a right lobe liver abscess. CT scan showed an atypical abscess like collection in segment 6 of the liver, with presence of calcified dense areas, assuming echinococcosis. However, immunology and serology showed no signs of parasite infection. At this point. information on previous (2 years) laparoscopic cholecystectomy was obtained. Considering location of the abscess, gallstones like finding on CT and previous cholecystectomy, abscess around spilled gallstones was suspected and surgery recommended. The method of mini-invasive extraperitoneal video assisted approach was agreed upon. With ultrasound guidance, punction and subsequent miniincision was performed, in the 10th right intercostal space. Pus was evacuated and the cavity was investigated with standard laparoscope, locating 4 gallstones and extracting them with laparoscopic grasper. Lavage and insertion of two drains followed. Drains were regularly flushed with normal saline and left in place for 7 days. Further course was uneventful. Standard therapy of liver and subhepatic abscesses is percutaneous drainage, however retained gallstones as a permanent bacterial nidus need to be removed in order to heal the abscess completely. Miniinvasive extraperitoneal approach is an effective option. Spilled gallstones should be taken into consideration in cases of atypical intraabdominal abscesses ant information on previous gallbladder surgery.