Laparoscopic management of gallstone ileus

Abstract

Gallstone ileus is an uncommon entity that was first described by Bartholin in 1654. Despite advances in perioperative care, morbidity and mortality remain high in patients with gallstone ileus because: 1) they are geriatric patients; 2) they often have multiple comorbidities; 3) presentation to the hospital is delayed; 4) many are volume depleted with electrolyte abnormalities; and 5) the diagnosis of gallstone ileus is difficult to make. Traditional management has entailed open laparotomy with relief of intestinal obstruction by enterotomy and stone extraction. Cholecystectomy and takedown of the cholecystoenteric fistula can be performed. We propose an alternative method of management in an attempt to limit operative trauma and improve morbidity and mortality. We review the literature and describe two patients with gallstone ileus who were managed laparoscopically. One patient underwent laparoscopic assisted enterolithotomy, and the other patient underwent diagnostic laparoscopy with disimpaction of the gallstone into the large bowel. They were discharged after their ileus had resolved on the fourth and sixth postoperative day, respectively. Laparoscopy is a powerful diagnostic and therapeutic tool that can be effectively used to treat gallstone ileus.

Figure 1.

Plain abdominal radiograph of patient 1 demonstrates pneumobilia.

Figure 2.

SBS of patient 1 demonstrates obstruction of the jejunum with a 7 x 5-cm mass (arrow 1) and reflux of contrast into the gallbladder (arrow 2) and biliary tree (arrow 3) via a cholecystoduodenal fistula.

Figure 3.

6.3 x 4.5 x 4.2 cm gallstone extracted from the jejunum via a transverse enterotomy.

Figure 4.

Abdominal and pelvic CT of patient 2 demonstrates an oval-shaped, calcified mass obstructing the terminal ileum.