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European Journal of Radiology 83 (2014) 867–879

Contents lists available at ScienceDirect

European Journal of Radiology

j ourna l h om epage: www.elsev ier .com/ locate /e j rad

eview

maging in laparoscopic cholecystectomy—What a radiologist needso know

aman S. Desaia,1, Ashish Khandelwala,∗,1, Vivek Virmanib,eha S. Kwatraa, Joseph A. Ricci c, Sachin S. Sabooa

Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis street, Boston, MA, 02115, USADepartment of Radiology, Dr. Everett Chalmers Hospital, Priestman St, Fredericton, 700, NB E3B 5N5, CanadaDepartment of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA

r t i c l e i n f o

rticle history:eceived 13 November 2013eceived in revised form 16 February 2014ccepted 18 February 2014

eywords:

a b s t r a c t

Laparoscopic cholecystectomy is the gold standard treatment option for cholelithiasis. In order to properlyassess for the complications related to the procedure, an understanding of the normal biliary anatomy,its variants and the normal postoperative imaging is essential. Radiologist must be aware of benefitsand limitations of multiple imaging modalities in characterizing the complications of this procedure aseach of these modalities have a critical role in evaluating a symptomatic post-cholecystectomy patient.

aparoscopic cholecystectomyholelithiasisiliary tract surgical procedureost-cholecystectomy syndrome

The purpose of this article is describe the multi-modality imaging of normal biliary anatomy and itsvariants, as well as to illustrate the imaging features of biliary, vascular, cystic duct, infectious as wellas miscellaneous complications of laparoscopic cholecystectomy. We focus on the information thatthe radiologist needs to know about the radiographic manifestations of potential complications of thisprocedure.

© 2014 Elsevier Ireland Ltd. All rights reserved.

. Introduction

Laparoscopic cholecystectomy was first introduced in Europen 1980s [1]. It immediately gained widespread popularity dueo shorter hospital stay and earlier recovery to normal activities2]. However, in the hands of less experienced practitioners, ratesf complications secondary to the procedures have reported toe higher than traditional cholecystectomy [3]. Since laparoscopicholecystectomy has become the gold standard treatment of choiceor cholelithiasis, an understanding of normal biliary anatomy, itsariants and normal postoperative imaging of laparoscopic chole-ystectomy is essential to properly assess for the complicationselated to the procedure. Additionally, as sonography, computedomography (CT), Endoscopic retrograde cholangiopancreatogra-

hy (ERCP), and Magnetic resonance cholangiopancreatographyMRCP) all have a role to play in evaluating a symptomatic post-holecystectomy patient [4], radiologist must be aware of relative

∗ Corresponding author. Tel.: +1 6178385987; fax: +1 617 264 6802.E-mail addresses: nsdesai@partners.org (N.S. Desai), drashish83@gmail.com,

khandelwal1@partners.org (A. Khandelwal), drvivek.virmani@horizonnb.caV. Virmani), nkwatra@partners.org (N.S. Kwatra), jaricci@partners.org (J.A. Ricci),saboo@partners.org (S.S. Saboo).

1 Both authors have contributed equally to the manuscript.

ttp://dx.doi.org/10.1016/j.ejrad.2014.02.016720-048X/© 2014 Elsevier Ireland Ltd. All rights reserved.

benefits and limitations of each modality in characterizing compli-cations of the procedure. In this article, after describing the imagingof normal biliary anatomy and its variants, we systematically illus-trate imaging features of biliary, vascular, cystic duct complications,along with infections and miscellaneous complications of laparo-scopic cholecystectomy.

2. Technique of laparoscopic cholecystectomy

Basic surgical steps of performing a laparoscopic cholecystec-tomy are as follows [5]: after insufflating the peritoneal cavity with3–4 L of carbon dioxide through a periumbilical incision, the pri-mary trocar and laparoscope are placed. After ruling out any injuryresulting from placing of the primate trocar, three accessory trocarsare placed. Subsequently, the gallbladder is grasped at the fundus;retracted cephalad and both cystic duct and artery are isolated. Adouble clip is then placed on the cystic duct and artery. The cysticduct is incised; the gallbladder is dissected off the liver bed, and issubsequently removed.

Before ligating the cystic duct and artery, contents of the hep-

atocystic triangle, the area formed by the gallbladder and cysticduct medially, common hepatic duct laterally and inferior liveredge superiorly, should be carefully identified. Misidentificationof anatomy in this area is in fact a major cause of complications

868 N.S. Desai et al. / European Journal of Radiology 83 (2014) 867–879

Fig. 1. Schematic presentation showing Hepatocystic triangle. The hepatocystic tri-angle is formed by the common hepatic duct (CHD) to the left, the proximal part ofthe gallbladder and cystic duct (CD) to the right, and the margin of the right lobe ofthe liver superiorly. Originally, the triangle was described by Calot as having cysticah

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rtery (CA) as the upper boundary. CBD, Common bile duct. LHA/RHA, Left and rightepatic arteries.

uring the surgery (Fig. 1) [6]. Calot’s triangle is the historic nameor this space and was originally described to be bounded byhe cystic duct, the common hepatic duct, and the cystic arteryFig. 1). Calot’s triangle, containing the cystic artery, may also con-ain an aberrant/accessory hepatic artery or anomalous bile ducts.issection in the triangle of Calot is not recommended until the

ateral-most structures have been clearly defined and identificationf the cystic duct is ascertained.

. Biliary anatomy and its variants

Gallbladder, located in the fossa on the undersurface of the liver,s approximately 10 cm long and 5 cm in diameter. It is attached to

ommon bile duct (CBD) via the 2–4 cm long cystic duct. The cysticuct usually enters from the right, approximately half way betweenhe porta hepatis and the ampulla of Vater. The insertion point ofhe cystic duct is variable [7]. In the first variation seen in 10–17%

ig. 3. Coronal MRCP image (A) and axial T2 weighted MR image (B) showing low insertio

Fig. 2. Coronal thick slab Magnetic resonance cholangiopancreatography (MRCP)image, showing medial insertion of the cystic duct (white arrow).

of cases, cystic duct joins CBD from the medial aspect (Fig. 2) anddrains into its left side. In the second variation seen in 1.5–2.5% ofcases, cystic duct has a parallel course relative to the CBD before itspirals around it to insert medially. In the third variation, there isa low cystic duct insertion, usually in the distal third of the CBD,in approximately 9% of cases (Fig. 3). After a laparoscopic chole-cystectomy, cystic duct remnant is usually 1–2 cm long; however,remnants up to 6 cm in length have been seen in the case of longparallel or low and medial insertions.

The classic biliary anatomy, which is seen in 50–60% of patients,

consists of the right hepatic duct draining the right hepatic lobe,and the left hepatic duct draining the left lobe (Fig. 4) [8]. Theright hepatic duct branches into the right anterior duct (RAD),which drains segments V and VIII, and the right posterior duct

n of the cystic duct (white arrow) with parallel course to common bile duct >2 cm.

N.S. Desai et al. / European Journal of Radiology 83 (2014) 867–879 869

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ig. 4. Coronal reconstructed thick slab MRCP image showing normal hepatic duct aosterior duct drains segments VI and VII; Left hepatic duct drains segments II–IV;

RPD), which drains segments VI and VII. The right posterior ductuns posterior to the right anterior duct and fuses in a medial-ided approach to form a short right hepatic duct [9]. Left hepaticuct (LHD) drains segments II–IV through smaller segmental ducts.ommon hepatic duct is formed via the fusion of left and rightepatic ducts. The caudate lobe duct can drain directly either intohe left or the right hepatic duct.

Variant biliary anatomy is one of the important causes of biliaryuct injury during laparoscopic cholecystectomy [10]. There arehree common variations to the classic biliary anatomy. Drainagef the RPD into the LHD before its confluence with RAD is one of theost common variants, seen in 15% of cases (Fig. 5A) [11]. Triple

onfluence pattern in which there is a simultaneous emptying ofhe RPD, RAD, and LHD is seen approximately 11% of cases (Fig. 5B)11]. Direct drainage of the RPD into the common hepatic duct from

he right (seen in 5%) or the left (seen in <1%) is called aberrantepatic duct (Fig. 6). The close proximity of the aberrant hepaticuct to hepatocystic angle makes it vulnerable to injury, leading toiliary fistula, sepsis, and biloma [10].

ig. 5. Coronal MRCP image (A) showing drainage of right posterior duct (RPD) into leftRCP image in another patient (B) showing triple confluence pattern with simultaneous

y seen in 50–60% of patients. Right anterior duct drains segments V and VIII; Rightte lobe duct can drain into either left or right hepatic duct.

Accessory hepatic ducts, seen in 2% of cases, may drain into theright or the left ductal system. They may be described by theirlocation relative to the gallbladder as supravesicular (superior tothe gallbladder body) or subvesicular (inferior to the gallbladderbody). These can be accidently injured during cholecystectomy(Fig. 7). Thus, radiologists should always report variant biliaryanatomy, as it is one of the leading causes of iatrogenic injuriesduring laparoscopic cholecystectomies.

4. Biliary complications

4.1. Biliary injury

Bile leakage secondary to bile duct injury is the most commoncomplication of laparoscopic cholecystectomy [12]. In one series,

there was a 0.6% overall rate of bile duct injury, with the rate forindividual surgeons varying from 0.4% to 4% [13]. Most leaks occurfrom the cystic duct stump. Some common mechanisms of leakinclude dislodgement of clips from the cystic duct stump as well

hepatic duct (LHD) before its confluence with right anterior duct (RAD). Coronalemptying of RPD, RAD and LHD.

870 N.S. Desai et al. / European Journal of Radiology 83 (2014) 867–879

Fig. 6. Coronal MRCP image (A) and axial T2W image (B) showing aberrant right posterior duct draining into the CBD (white arrow). Failure to recognize this anomaly is them

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biloma. In type D injury, there is partial injury to common hepatic

ost common cause of biliary injury in cholecystectomy.

s unintentional laceration, transection or thermal injuries of theuct. Hepatobiliary scintigraphy, ERCP, or mangafodipir trisodiumnhanced T1-weighted MRCP have been shown to be effective inhe diagnosis of bile leak [14].

Based on severity of the injury, biliary injury can be classifiednto Type A through Type E using the schema proposed by Stras-erg SM et al. [15]. This classification describes spectrum of biliary

njuries from asymptomatic bile leak, to complete obstruction ofhe biliary tree. In the type A injuries, there is leakage into the gall-

ladder bed from injury to either the minor hepatic ducts or theystic duct without injuries to major bile ducts or hepatic ductsFig. 8). There is no loss of continuity of the biliary tree. This type of

ig. 7. Endoscopic retrograde cholangiopancreaography (ERCP) image showingccessory hepatic duct draining into the common hepatic duct (white arrow). Patientad injury during cholecystectomy resulting in active contrast extravasation (blackrrow).

injury is usually the least serious. In type B and C injuries, there is anocclusion (Type B) or transection (Type C) of the part of the biliarytree. These injuries are usually associated with occlusion/ligationof aberrant right hepatic duct when there is cystic duct drainageinto the aberrant right hepatic duct and it is mistaken for the cys-tic duct [15]. Patients with Type B injury may be asymptomatic orpresent late with focal ductal dilatation and segmental atrophy ofliver (Fig. 9). Patients with Type C injury usually present early with

duct or common bile duct with a resultant biliary leak (Fig. 10). Theycan usually be managed with an endoscopic insertion of a t-tube.Type E injuries result from injury to the main biliary ducts and are

Fig. 8. ERCP image in a 46-year-old female with leak from the cystic duct remnant(white arrow) presenting 2 days after laparoscopic cholecystectomy. This representsStrasberg type A injury.

N.S. Desai et al. / European Journal of Radiology 83 (2014) 867–879 871

Fig. 9. 37-year-old female with post-laparoscopic transection of aberrant right posterior duct with persistent pain and elevated bilirubin levels post-operatively. (A) AxialT2W MRI done 1 week after laparoscopic cholecystectomy reveals mild prominence of the right posterior ducts (thick white arrow). (B and C) Axial T2W MRI done 1 yearlater reveals progressive dilatation of the right posterior hepatic ducts (thin white arrows) with segmental atrophy of the liver lobe (arrowhead). (D) VRT image from CT(thick white arrow) shows injury to right posterior hepatic duct. These findings are characteristic of Type B injury, may be asymptomatic or present late with focal ductaldilatation and segmental atrophy of liver.

Fig. 10. 42-year-old female presenting with abdominal pain and fever. (A) Coronal T2W MRI and (B) Heavily T2W MRCP reveals a collection/biloma in the gallbladder fossa(arrowhead) extending to the gastrohepatic region (arrow). (C) ERCP demonstrates contrast extravasation from the lateral aspect of the proximal CBD (arrow) representingp

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artial transection. This represents a type D injury.

lassified according to the level of injury: in E1, the injury occurs

2 cm from the confluence of left and right hepatic ducts (Fig. 11),hile in E2, the injury occurs <2 cm from the confluence (Fig. 12).

n E3, there is injury at the confluence, with the confluence beingntact, while in E4, there is destruction of the biliary confluence

ig. 11. 32-year-old female presenting with post-cholecystectomy pain with rising bilirB) Coronal HASTE MRI reveal multiple clips placed across the CBD (arrows) and transectio the confluence and is a Type E1 injury.

with separation of the major ducts. In E5, there is transection of

the aberrant right hepatic duct and the major ducts. With type Einjuries, patients usually present with symptoms such as jaundiceand abdominal pain weeks after the surgery and a hepaticojejunos-tomy is almost always required [16].

ubin and obstructive symptoms. (A) Coronal Fat-saturated heavily T2 WI MRI andng it with resultant biliary tree dilatation. The transection is more than 2 cm distal

872 N.S. Desai et al. / European Journal of Radiology 83 (2014) 867–879

Fig. 12. 42-year-old female with abdominal pain and obstructive symptoms 1 day after laparoscopic cholecstectomy. (A) ERCP reveals a transection of the common hepaticd ontrasp ostom

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uct (white arrow) (<2 cm from the confluence, representing type E2 injury) with claced as a temporary measure; the patient subsequently underwent hepaticojejun

.2. Stone retention and Mirizzi’s syndrome

Stone retention is an important complication of laparo-copic cholecystectomy, with incidence between 1.1% and 7%

ig. 13. Mirizzi’s syndrome secondary to calculus in the cystic duct remnant compressing to compression by calculus (arrowhead in C) in the cystic duct remnant which is also dila

t in the drain (white triangle) indicating active leak. (B) A stent (white arrow) wasy.

[17]. Patients usually presents with symptoms of biliary colic.

Factors predisposing to retained stones include incompleteexcision of gallbladder due to adhesions and a long cystic duct pedi-cle. Retained stone case lead to increased biliary pressure resulting

he CBD. (A–D) Coronal TruFISP images reveal dilated biliary tree (arrows) secondaryted (dashed arrow).

N.S. Desai et al. / European Journal of Radiology 83 (2014) 867–879 873

Fig. 14. 55-year-old female presenting with obstructive jaundice and abdominal pain 2 days after laparoscopic cholecystectomy. The preoperative MRCP (not shown) didn rrowt e CBD

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ot show any CBD calculi. (a and b) The postoperative MRI reveals a large calculus (ahe calculus. It was presumed that this was a slipped calculus which migrated to th

n displacement of cystic duct clips and a bile leak. Addition-lly, gallstone impaction in the cystic duct remnant can cause an

nflammatory reaction, leading to extrinsic bile duct com-ression thus resulting in Mirizzi’s syndrome (Fig. 13). Post-holecystectomy Mirizzi’s syndrome can usually be successfully

ig. 15. 65-year-old male presenting with persistent fever and pain 2 week post-laparoscoercutaneously. Initial CT (A) without oral contrast reveals pneumobilia (yellow arrowsrain (arrowheads in B) is also visualized. Subsequent repeat CT with oral contrast and dehe findings are diagnostic of a choledochoduodenal fistula. 3D surface-shaded (D) imagyellow arrows) and the CBD (white arrow) through the abscess cavity being drained by t

) in the CBD with biliary tree dilatation. (c) The subsequently done ERCP also shows intraoperatively while manipulating the gallbladder.

managed with ERCP [18]. Similarly, since CBD is not exploredduring laparoscopic cholecystectomy, a gallbladder stone can

migrate into the CBD in patients with patulous cystic duct whengallbladder is pulled in a cephalad direction during cholecys-tectomy, causing biliary obstruction (Fig. 14). In patients with

pic cholecystectomy. Patient has a history of known post-op abscess being drained). The known abscess in the gall bladder fossa being treated with a percutaneouslayed scan 10 min later demonstrated oral contrast in the biliary tree (arrows in C).es of the CT reveal a communication (yellow arrowheads) between the duodenumhe tube (red arrowheads).

874 N.S. Desai et al. / European Journal of Radiology 83 (2014) 867–879

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ig. 16. 48-year-old female presenting with abdominal pain and elevated liver enzmooth stricture (arrow) in the CHD with a non-obstructive calculus in the distal CBmooth CHD stricture (arrow) causing biliary tree dilatation. Post-cholecystectomy

uspected stone retention, MRCP is helpful in depicting thesetones, while ERCP can allow for diagnosis and stone extraction.

.3. Choledochoduodenal fistula

Although rare, choledochoduodenal fistula formation has beeneported as one of the late complications of laparoscopic cholecys-

ectomy [4]. Patients can present with fever and abdominal pain. CTithout oral contrast may reveal pneuomobilia, while addition of

ral contrast exhibits opacification of biliary tree (Fig. 15). However,RCP is the most accurate imaging modality for the diagnosis of

ig. 17. 55-year-old female with elevated liver function tests and abdominal pain 6 mholecystectomy clips (circled) with an inferiorly displaced clip (arrow). (B–D) Axial anonsequent CBD dilatation (arrowhead).

6 months after laparoscopic cholecystectomy. (A) MRCP image reveals an eccentricowhead). (B and C) ERCP reveals the non-obstructive calculus (arrowhead) and the(dashed arrow) are seen close to the stricture.

choledochoduodenal fistula [19]. Such fistulous complications canbe successfully managed using endo-stapling devices, thus avoid-ing peritoneal contamination [20].

4.4. Stricture formation

Due to widespread use of laparoscopic cholecystectomy in the

management of cholelithiasis, the incidence of late biliary obstruc-tion secondary to stricture formation has increased [21]. Biliarystrictures usually develop a few months to many years after the ini-tial surgery. Etiology of stricture formation includes thermal injury

onths after laparoscopic cholecystectomy. (A) Abdominal X-ray reveals multipled coronal CT images reveal the displaced clip (arrow) within the distal CBD with

nal of Radiology 83 (2014) 867–879 875

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Fig. 18. Mucocele in a cystic duct remnant. 84-year-old male presenting withright hypochondrial pain with history of laparoscopic cholecystectomy. Contrast-enhanced CT reveals dilated cystic duct remnant (arrowhead) compressing the

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N.S. Desai et al. / European Jour

uring the surgery and irritation from surgical clips causing fibrosisnd eventually leading to stricture formation [22]. MRCP allows forccurate diagnosis, while ERCP provides both diagnostic and ther-peutic options. Imaging findings include intra and extrahepaticuctal dilatation with gentle tapering, focal ductal narrowing, andon-depiction of a part of a duct (Fig. 16). The number and locationf strictures is important to report since it is essential for surgicallanning.

.5. Post-cholecystectomy clip migration

Post-cholecystectomy clip migration (PCCM) is a rare butell-known complication of laparoscopic cholecystectomy [23].ommon presentations of PCCM include obstructive jaundice,holangitis, biliary colic, and acute pancreatitis, usually secondaryo clip-related biliary obstruction (Fig. 17). Most common site of

igration is into the CBD. Many factors contribute to clip migra-ion including inaccurate clip placements with resultant bile ductnjuries, local suppurative inflammatory processes, bile leak withesultant biloma formation, and local infectious processes [24]. Inost cases, ERCP is the treatment of choice for clearance of the clip

nd clip-related biliary stones.

.6. Cystic duct complications

In addition to the aforementioned complications such asetained gallstone, Mirizzi’s syndrome and bile leak, mucocele

ig. 19. (A) 40 year-old-female 1 day post-laparoscopic cholecystectomy with right uppargely thrombosed lumen (white triangle) arising from the common hepatic artery (wharrow, B) arising from the common hepatic artery and coil embolization (arrow, C) was pehe thombosed lumen and coils are seen (arrow, D).

common hepatic duct (arrow).

formation in a cystic duct remnant should be in the differen-tial diagnosis in a post-cholecystectomy patient with biliary colic.During the surgical removal of the gallbladder, a blind-ending

cystic duct remnant is created that may become distended withmucous and impinge on the common hepatic duct, causing biliary

er quadrant pain. Axial CECT images demonstrate a large pseudoaneurysm with aite arrow). Subsequent angiography revealed the patent lumen of the aneurysm

rformed. Post-embolization CECT images does not reveal residual aneurysm lumen.

876 N.S. Desai et al. / European Journal of Radiology 83 (2014) 867–879

Fig. 20. Cholangitis and abscess formation in 64-year-old female presenting with fever 5 days after laparoscopic cholecystectomy. (A) Coronal CT image reveals thickeningand enhancement of the biliary tree (arrows) indicating cholangitis. (B) Post-contrast MR images subsequently reveals liver abscess (arrow) as a complication of cholangitis.

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bstruction (Fig. 18) [25]. Treatment of cystic duct remnant muco-ele is usually surgical [26].

. Vascular complications

Vascular complications secondary to laparoscopic cholecystec-omy have been noted in 1.8–4.1% of cases and include vascularnjury in the surgical bed, pseudoaneurysm formation (Fig. 19),nd incision/trocar site injuries [27,28]. The right common hepaticrtery followed by the portal vein are the two most common ves-els injured during gallbladder fossa dissections [29]. Bleeding fromnjury to liver parenchyma may occur in 10–15% of patients sec-ndary to close proximity of middle hepatic vein to the gallbladderossa [30]. Inadequate ligation of the cystic artery or clip dislodge-

ent after deployment can also result in hemorrhage.Hepatic artery pseudoaneurysm formation has been described

s a rare, but known complication of laparoscopic cholecystec-omy, and is attributed to bile leak and subsequent infection [31].f pseudoaneurysm formation is suspected, contrast-enhancedT should be performed, which may show a hematoma or theseudoaneurysm. Selective angiography of the celiac and SMA is

sually helpful in confirmation of the diagnosis and employmentf endovascular treatment.

While rare, blind insertion of the first trocar at the start ofhe procedure may cause perforation of abdominal wall vessels

ig. 21. (A) Axial, (B) coronal contrast enhanced CT of patient with known lung cancer anppears mottles hypodense on CT mimicking abscess (arrow).

such as inferior epigastric vessels [32] and the great vessels [33].Hematomas caused by these injuries can readily be diagnosed witha CT or sonogram. Late vascular complication can include portalvein thrombosis [34].

6. Infectious complications

Cholangitis and liver abscess are rare complications of laparo-scopic cholecystectomy. Development of cholangitis occurs moreoften when there is biliary bacterial contamination, stagnant bile,and increased intra-biliary pressure (>20 mmHg), which can beseen with the various previously-described bile duct complicationsafter laparoscopic cholecystectomy including mucocele formation,Mirizzi’s syndrome, stone retention and PCCM [35]. With cholan-gitis, enhancement of intrahepatic biliary duct walls is a commonfinding on CT as well as MR [36]. Most common complications ofcholangitis includes abscess formation and portal vein thrombo-sis (Fig. 20) [36]. It is essential not to mistake the postoperativeappearance of Gelfoam on CT with abscess (Fig. 21).

Dropped gallstones are another important complication oflaparoscopic cholecystectomy resulting in abdominal wall or per-

itoneal abscess formation (Fig. 22) [37]. Spillage of gallstonesoccurs infrequently with the procedure, with reported incidence of0.1–20%, even though perforation of gallbladder is seen in 10–40%of cases [38]. Diagnosis of abscess secondary to dropped gallstones

d splenic metastasis (arrowhead). Gelfoam packing material post-cholecystectomy

N.S. Desai et al. / European Journal of Radiology 83 (2014) 867–879 877

Fig. 22. 65-year-old female presenting with pyrexia 6 months after laparoscopicc(g

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Fig. 24. 58-year-old female, 6 days post-laparoscopic cholecystectomy, presentingwith fever, chills, leucocytosis and right upper quadrant tenderness. There was sig-nificant crepitus on palpation of right anterolateral abdominal wall. On the axialCT sections there is extensive air in the right anterior and lateral abdominal wall(arrow) predominantly in the subcutaneous fat, interspersed in the fascial plane ofthe oblique group of muscles and posterior to the right rectus sheath. No intraperi-toneal extension was seen. A diagnosis of necrotizing cellulitis was considered andsurgical debridement and skin grafting was done. Klebsiella was the culprit organ-

secondary to insufflation of gas as well as intestinal ischemia anddelayed bowel perforation secondary to thermal injury have allbeen reported as complications of laparoscopic cholecystectomy(Fig. 26) [42,43].

holecystectomy. Coronal contrast CT reveals subhepatic (arrow) and subphrenicdashed arrow) abscesses with calcific densities within them representing droppedallstones.

s difficult to make, as it usually presents months to years afterhe procedure. On imaging, dropped gallstones are most commonlyeen in the subhepatic or subdiaphragmatic space, but rarely cane seen in the pelvis (Fig. 23) [39]. If caused by calcified gallstones,bscesses may contain calcific densities in or around the abscessite on CT, which is the key to the diagnosis.

Infection at the port site after laparoscopic cholecystectomy has reported incidence of 2.7% [40]. Patients usually presents withain at the site with fever and elevated WBC. Contrast-enhancedT is usually diagnostic, revealing stranding with or without airFig. 24). Spillage of gallstone(s) may rarely be the cause of anteriorbdominal wall inflammation (Fig. 25).

. Other complications

Less prevalent complications of laparoscopic cholecystectomyan also be diagnosed via cross-sectional imaging. Reported

ig. 23. Example of incidentally detected dropped gallstones in the pelvis (arrow)n axial CT section at the level of femoral head. No associated complications wereeen.

ism.

incidence of trocar site hernia is between 0.02% and 3.6% [41].Umbilical hernia at the site of the midline trocar is the most com-mon type. It usually occurs between a few days to months aftersurgery, and rarely may be complicated by small bowel obstruc-tion or panniculitis. Even though may be suggested by a herniatingmass at the port site on physical exam, CT is usually diagnostic.Additionally, perforation of visceral organs and intestinal ischemia

Fig. 25. G all stone spillage in a 55-year-old woman with a history of laparoscopiccholecystectomy 4 months back and presenting with right upper quadrant pain.Axial contrast CT reveals a gallstone (arrow) at the trocar site in the abdominal wallwith adjacent inflammation.

878 N.S. Desai et al. / European Journal of Radiology 83 (2014) 867–879

Fig. 26. Post-laparoscopic cholecystectomy patient developed fistula from small bowel to skin from port site due to small bowel injury. CT (A and B) shows direct commu-n ing o

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. Conclusion

Purported complication rate after laparoscopic cholecystectomys only 3% [44]. However, since it has become the gold standardreatment of choice for cholelithiasis, an understanding of normaliliary anatomy, its variants and normal postoperative imaging of

aparoscopic cholecystectomy is essential to properly assess theomplications related to the procedure. Every radiologist needs toe knowledgeable about the radiographic manifestations and inter-entional radiologic management of the potential complications ofhis procedure.

onflict of interest

None.

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