GALL STONE PAIN AFTER LAPAROSCOPIC CHOLECYSTECTOMY

Few percentage patients after gall bladder surgery will come with same pain as before gall bladder surgery. The common reasons are,

       1). RETAINED CYSTIC DUCT STONE

       2). RESIDUAL COMMON BILE DUCT STONE

       3). COMMON BILE DUCT STONE

       4). RESIDUAL GALL BLADDER WITH STONE (POST SUBTOTAL CHOLECYSTECTOMY) 

RETAINED CYSTIC DUCT STONE

       One of the reasons for pain after gall bladder surgery in gall stone disease is presence of stone in the cystic duct. The presence of stone in the cystic duct is usually associated with remanent gall bladder. The remanent gall bladder enlarges in size and end up with development of biliary colic. The presence of cystic duct stone leads to remanent gall bladder contraction after each food. So, during each contraction, the pressure within the remanent gall bladder is increased and that is the reason for pain. So, during gall bladder removal surgery care should be taken to milk back the stone from the cystic duct to gall bladder and also to remove entire gall bladder with cystic duct.

      Sometime small stone left in the cystic duct leads to recurrent abdominal pain related to each food intake. The common reason for this pain is that slippage of stone into the bile duct can leads to pain abdomen with jaundice. The reasons for retained stone in the cystic duct are:

         1). Slippage of stone from gall bladder to cystic duct during surgery.

         2). Poor visualization of cystic duct during surgery due to severe inflammation of this area.

         3). Unnoticed cystic duct stone during surgery which is very rare.

         4). Leaving long cystic duct. The length of cystic duct left behind during surgery should not exceed more than 5mm. If the length of leftover cystic duct is more than 5mm that may end up with new stone formation.

      The diagnosis is usually confirmed with LFT and MRCP. LFT will be normal if the stone is confined to cystic duct.

     The treatment is to remove the left-over cystic duct with stone which can be done by laparoscopy technique or open surgical technique. The laparoscopic removal of retained cystic duct will be technically demanding procedure. 

RESIDUAL COMMON BILE DUCT STONE

       Some patient come to the hospital with abdominal pain and evaluation reveals gall stone disease. Liver function test will be normal. But there is a possibility of stone in common bile duct which was not diagnosed before surgery. This ends up with pain abdomen after surgery similar to gall stone disease. Diagnosis is by MRCP and the treatment is ERCP and stone extraction.

     Sometime patient who had undergone ERCP before surgery may have one or more left over stones which can also present with similar pain and the diagnosis and treatment are same.

COMMON BILE DUCT STONE

        There is a possibility of migration of stone from gall bladder to the common bile duct just before surgery or during surgery. This present as pain abdomen similar to gall stone disease. Liver function test (LFT) and MRCP confirms the diagnosis. Treatment is to do ERCP and remove the stones.

RESIDUAL GALL BLADDER WITH STONES   (POST SUBTOTAL CHOLECYSTECTOMY)

    Removal of entire gall bladder is very important to prevent the recurrence of gall stone related symptoms. The idea of doing gall bladder surgery is to remove the entire gall bladder with a part of cystic duct and gall stones. In case of severe acute or chronic infection there may be technical difficulty in identifying the anatomy clearly. The demonstration of the cystic duct and Common bile duct junction may be difficult. There is also a possibility of long and parallel cystic duct which may leads to incomplete removal of Gallbladder end up with leaving behind a small portion of gall bladder (residual gallbladder). This may end up with enlargement of this bladder sometime after surgery and stone formation in this retained residual gall bladder. The clinical presentation is similar to biliary colic with acute or chronic cholecystitis.

    Sometime chronic infection of Gallbladder leads to thickening and adhesions over Calot’s triangle. In this situation, Surgeon prefers to leave behind a small part of Gallbladder attached to the cystic duct known as Sub-total cholecystectomy. This technique prevents the damage to biliary system.

    Diagnosis is done with ultrasonography of abdomen and confirmed with MRCP evaluation. Treatment is to remove the residual gall bladder by laparoscopic or open technique.