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JAMA Surgery Clinical Challenge
September 2016

Progressive Abdominal Pain Following Laparoscopic Cholecystectomy

Author Affiliations
  • 1Division of Acute Care Surgery, University of Southern California, Los Angeles
JAMA Surg. 2016;151(9):871-872. doi:10.1001/jamasurg.2016.0980

A 51-year-old man presented with a 2-day history of right upper quadrant abdominal pain. Ultrasonography of the abdomen’s right upper quadrant showed gallbladder wall thickening with gallstones in the neck of the gallbladder consistent with acute calculous cholecystitis. He subsequently underwent a laparoscopic cholecystectomy. The critical view of safety1 was obtained, and the gallbladder was removed from the fossa without difficulty. On extraction of the gallbladder through the umbilical incision, a large stone in the gallbladder could be palpated. After several attempts of extraction, the retrieval bag perforated and stones spilled into the abdomen. Not all the spilled stones could be retrieved. The patient had an uncomplicated postoperative course and was discharged to home on postoperative day 2. Two weeks after surgery, he was evaluated for persistent mild abdominal pain in clinic. Computed tomography (CT) of the abdomen showed a 2.5-cm calcified mass with adjacent inflammatory changes in the left hemiabdomen that was most consistent with a lost gallstone (Figure 1A). He returned to the emergency department 1 month later with a 2-day history of progressive abdominal pain, nausea, and vomiting. He denied fever and chills. Results of a physical examination revealed mild abdominal tenderness in the left lower quadrant. Laboratory findings were unremarkable. A second abdominal CT was performed (Figure 1B).

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