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Special Feature
January 2013

Image of the Month—Diagnosis

Author Affiliations


JAMA Surg. 2013;148(1):100. doi:10.1001/jamasurgery.2013.410b
Answer: Abscess Due to a “Lost” Stone During the Previous Cholecystectomy

The surgical exploration confirmed the hypothesis of an abscess due to a spilled gallstone. The stone was removed, the area washed, and the patient fully recovered. Although the positron emission tomographic/computed tomographic imaging was performed owing to the patient's history of cancer, a recurrent vulvar cancer was unlikely because the peritoneum is a rare primary site of vulvar cancer metastasis.

Gallbladder perforation with or without bile and stone spillage is a relatively common event (reported in up to 40% of laparoscopic cholecystectomies).1 It occurs more frequently during laparoscopic procedures than open laparoscopic procedures, performed by junior surgeons, in male and/or elderly patients, and in the presence of a severely inflamed gallbladder and intra-abdominal adhesions.2

Although most spilled stones can be found and extracted during the same cholecystectomy procedure, some 0.8% to 1% of patients secondarily present with a stone-related complication.3 They often appear late after the cholecystectomy (up to several years) with abdominal pain and signs of infection, due to a local abscess.4 The mechanism by which gallstones induce the abscess is not completely understood, but pigmented and large (>1.5 cm) stones appear to be more often involved.5,6 Other potential stone-related complications include the occurrence of adhesions, fistula, obstruction, intestinal perforation, and pleural empyema.7 In case of a stone spillage during a cholecystectomy, the abdominal cavity should be carefully explored with the removal of as many stones as possible and with intense irrigation.6

In summary, the present case illustrates the risk of an abscess linked to lost stones, which can appear years after cholecystectomy (10 years in the present case). Such a diagnosis should be considered in case of inflammation/abscess at the surface of the lower part of the right lobe of the liver for patients who had a cholecystectomy. Every effort should be made to find and remove lost stones during cholecystectomy.

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Due to the overwhelmingly positive response to the Image of the Month, the JAMA Surgery has temporarily discontinued accepting submissions for this feature. Requests for submissions will resume in April 2013. Thank you.

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Article Information

Correspondence: Théodoros Thomopoulos, MD, Department of Surgery, Abdominal and Transplant Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211 Genève 14, Switzerland (

Accepted for Publication: December 16, 2011.

Author Contributions:Study concept and design: Mentha and Toso. Acquisition of data: Mentha and Toso. Analysis and interpretation of data: Thomopoulos, Mentha, and Toso. Drafting of the manuscript: Toso. Critical revision of the manuscript for important intellectual content: Thomopoulos and Mentha. Administrative, technical, and material support: Thomopoulos. Study supervision: Mentha and Toso.

Conflict of Interest Disclosures: None reported.

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