Teaching points
85% of the patients after laparoscopic cholecystectomy become symptom free. However 5% produced symptoms referred to as post cholecystectomy syndrome. The causes could be biliary stricture / Remnant stump calculi / dyskinesia / cystic neuroma / idiopathic.
Laparascopic technique though has been established involves technique which could leave long cystic duct stump. Radiologically when evaluated, this dilated tubular structures in and around the gall bladder fossa is difficult to differentiate whether it is a stump of the duct or remnant of the gall bladder. Long cystic duct stump is defined as more than 1 cm in length. Rogers etal after extensive study, concluded that leaving along cystic duct stump is not risk factor for remnant calculi. Though differences of opinion exists it is now recommended the total excision of the duct is ideal.
Calots triangle ( inferior edge of the liver forming superior border, common hepatic duct medial border and cystic duct inferior border with cystic artery as the contents) contributes to be an important land mark for identification of the cystic duct / gall bladder junction.
This 29 yr old young lady operated 2 years back for cholelithiasis has recurrent abdominal pain especially with fatty foods. This case represent a long tubular dilatation at the end of an apparent convoluted cystic duct ( measuring approximately 4.5 cm), possibly the remnant gall bladder in an operated cholelithiasis with adhesions. As the patient is periodically symptomatic, re-exploration and excision of the remnant of the gall bladder along with long cystic duct stump is recommended depending on the progress. Case submitted by Dr MGK Murthy
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