Stump cholecystitis is a rare but clinically significant condition that occurs when inflammation develops in the remnant of the gallbladder or cystic duct following an incomplete cholecystectomy. It presents with symptoms similar to gallbladder disease, such as right upper quadrant pain, fever, jaundice, or dyspepsia, leading to diagnostic challenges. With the widespread adoption of laparoscopic cholecystectomy as the gold standard for gallbladder removal, most cases of stump cholecystitis today are managed using minimally invasive surgery.

Understanding Stump Cholecystitis

During a difficult or complicated cholecystectomy, especially in the setting of severe inflammation, dense adhesions, or abnormal anatomy, surgeons may leave behind a portion of the gallbladder or a long cystic duct stump to avoid injury to the common bile duct. Over time, this residual tissue can harbor gallstones or become inflamed, resulting in stump cholecystitis.

The incidence is low but important because it often leads to recurrent biliary symptoms after what was thought to be definitive gallbladder removal. Diagnosis requires a high index of suspicion, as patients may present months or even years after the initial surgery.

Clinical Features

Symptoms of stump cholecystitis mimic acute cholecystitis or choledocholithiasis and may include:

Recurrent right upper quadrant or epigastric pain.

Fever, nausea, and vomiting during acute episodes.

Jaundice, if there is associated bile duct obstruction.

Indigestion and bloating after fatty meals.

Imaging studies such as ultrasound, MRCP (Magnetic Resonance Cholangiopancreatography), or CT scan often reveal a residual gallbladder remnant or stones in the cystic duct stump.

Indications for Surgery

Definitive treatment for stump cholecystitis is completion cholecystectomy, where the remaining gallbladder tissue and cystic duct stump are excised. While open surgery was traditionally performed due to technical difficulties, advances in laparoscopic techniques now make laparoscopic completion cholecystectomy a safe and feasible option in most cases.

Indications include:

Symptomatic patients with recurrent right upper quadrant pain.

Evidence of stones in the residual gallbladder or cystic duct.

Complications such as bile leak, abscess, or fistula formation.

Laparoscopic Surgical Technique
Preoperative Preparation

Detailed imaging, often with MRCP, is crucial to delineate biliary anatomy and avoid injury to the common bile duct.

Patients are optimized with antibiotics, fluids, and correction of electrolyte imbalances if acute infection is present.

Anesthesia and Positioning

The procedure is performed under general anesthesia.

The patient is positioned supine with slight reverse Trendelenburg and left tilt for better exposure of the right upper quadrant.

Operative Steps

Port placement – Similar to standard laparoscopic cholecystectomy, typically four ports are used. Adhesions from prior surgery may require modifications.

Adhesiolysis – Careful dissection is carried out to free dense adhesions from the liver, omentum, and duodenum around the gallbladder fossa.

Identification of the remnant – The gallbladder stump is visualized, often appearing as a thickened sac or dilated cystic duct.

Dissection of Calot’s triangle – Meticulous dissection is performed to identify the cystic duct and artery. In some cases, the cystic artery may already have been divided during the first surgery.

Critical view of safety – Ensuring clear identification of structures before division is crucial to prevent bile duct injury.

Division and removal – The residual gallbladder tissue and cystic duct stump are clipped, divided, and removed.

Hemostasis and irrigation – The operative field is checked for bleeding or bile leak before closing the ports.

Challenges in Laparoscopic Completion Cholecystectomy

Dense adhesions from the previous surgery obscure anatomy and increase the risk of bile duct injury.

Altered landmarks due to partial resection make orientation difficult.

Close proximity of vital structures such as the common bile duct and hepatic artery requires precision.

In very difficult cases, conversion to open surgery remains a safe alternative, but experienced laparoscopic surgeons can usually complete the procedure minimally invasively.

Postoperative Care

Recovery after laparoscopic completion cholecystectomy is similar to standard laparoscopic cholecystectomy:

Pain control with oral analgesics.

Early ambulation to reduce thromboembolic risk.

Oral feeding resumed within 24 hours.

Hospital stay usually 2–3 days, depending on the severity of adhesions and intraoperative findings.

Outcomes and Benefits

Studies have shown that laparoscopic completion cholecystectomy provides:

Definitive relief of symptoms in the vast majority of patients.

Low recurrence of biliary colic or stump problems.

Shorter recovery time compared to open surgery.

Minimal scarring and improved cosmetic results.

Although technically more demanding than primary cholecystectomy, outcomes are excellent when performed in specialized centers.

Risks and Complications

Potential risks include:

Bile duct injury – the most feared complication.

Bile leak from the cystic duct stump.

Bleeding from adhesiolysis.

Infection or port site complications.

Conversion to open surgery if anatomy is unclear.

Meticulous technique, proper imaging, and surgeon expertise minimize these risks.

Conclusion

Laparoscopic completion cholecystectomy for stump cholecystitis is a challenging yet effective procedure that provides definitive relief to patients suffering from residual gallbladder disease. While adhesions and distorted anatomy make the surgery technically demanding, the benefits of a minimally invasive approach—less pain, quicker recovery, and excellent long-term outcomes—make it the preferred option in experienced hands. As awareness of stump cholecystitis increases and imaging improves, timely diagnosis and surgical management will ensure optimal results for patients.