This video demonstrate Stump cholecystitis is a recognised condition in which a large gallbladder remnant becomes inflamed after subtotal cholecystectomy. Stump cholecystitis is a recognised condition in which a large gallbladder remnant becomes inflamed after subtotal cholecystectomy.When this occurs, a completion cholecystectomy is indicated. She had an uneventful laparoscopic completion cholecystectomy performed.

Stump cholecystitis is an uncommon but clinically significant cause of post-cholecystectomy syndrome. It occurs when a residual portion of the gallbladder or cystic duct stump becomes inflamed, usually due to retained or recurrent calculi. With the increasing use of subtotal cholecystectomy in difficult gallbladder surgeries, the incidence of gallbladder remnants has increased slightly, making stump cholecystitis an important condition for surgeons to recognize and manage. Laparoscopic completion cholecystectomy has emerged as a safe and effective treatment modality for this condition when performed by experienced surgeons.

Definition and Pathophysiology

Stump cholecystitis refers to inflammation of a residual gallbladder remnant or cystic duct stump after a prior cholecystectomy. It most commonly occurs after subtotal cholecystectomy, which is performed when safe dissection of Calot’s triangle is not possible due to severe inflammation, fibrosis, or distorted anatomy. Studies suggest subtotal cholecystectomy is performed in a small percentage of difficult cases, and a minority of these patients may require reoperation later due to symptoms or recurrent disease.

Residual mucosa and retained stones can lead to recurrent inflammation, infection, and biliary colic. Closure of the stump during subtotal cholecystectomy is important to reduce complications such as bile leak and stump-related pathology.

Clinical Presentation

Patients typically present months to years after initial surgery with:

• Right upper quadrant abdominal pain

• Nausea and vomiting

• Fever (if acute inflammation present)

• Jaundice (rare, if associated biliary obstruction exists)

Radiological investigations such as ultrasound, MRCP, or CT scan help confirm the diagnosis by demonstrating a gallbladder remnant or cystic duct stump stones.

Indications for Laparoscopic Completion Cholecystectomy

The main indications include:

• Symptomatic gallbladder remnant stones

• Recurrent cholecystitis in gallbladder stump

• Cystic duct stump calculi

• Persistent post-cholecystectomy syndrome with confirmed remnant pathology

Laparoscopic re-exploration has shown good outcomes, low conversion rates, and minimal postoperative morbidity when performed in selected patients.

Preoperative Evaluation

Preoperative workup includes:

• Liver function tests

• Ultrasonography

• MRCP for biliary anatomy and stone detection

• ERCP if common bile duct stones suspected

Careful imaging is crucial because previous surgery often causes adhesions and distorted anatomy.

Surgical Technique: Step-by-Step Approach

1. Patient Position and Port Placement

• Standard laparoscopic cholecystectomy positioning

• Usually same port sites, but may need modification due to adhesions

2. Adhesiolysis

Dense adhesions between omentum, duodenum, and liver are common. Sharp and blunt dissection is performed carefully to avoid bowel injury.

3. Identification of Gallbladder Remnant

The remnant is usually located at the gallbladder fossa or cystic duct region. Intraoperative cholangiography may help delineate anatomy if unclear.

4. Dissection of Calot’s Triangle

This is often the most difficult step due to fibrosis and scarring. The surgeon must aim to achieve the critical view of safety if feasible.

5. Control of Cystic Duct and Artery

• Clips, sutures, or energy devices may be used

• In difficult cases, advanced suturing techniques or barbed sutures can be used to close fragile stumps safely.

6. Removal of Gallbladder Remnant

The remnant is dissected from liver bed and removed. Care is taken to ensure complete mucosal removal to prevent recurrence.

7. Drain Placement

Often recommended due to higher risk of bile leak in redo surgery.

Technical Challenges

• Dense adhesions from previous surgery

• Distorted biliary anatomy

• Increased risk of bile duct injury

• Higher operative time

Despite these challenges, laparoscopic completion cholecystectomy has been shown to be feasible and safe, even in resource-limited settings.

Outcomes and Prognosis

Studies show:

• Low conversion rates to open surgery

• Acceptable complication rates

• Short hospital stay

• Good symptomatic relief

One study of laparoscopic re-exploration showed minimal complications, rare bile leak, and no mortality.
Another study demonstrated that completion laparoscopic cholecystectomy can be performed safely with acceptable morbidity, although operative time may be longer than primary surgery.

Complications

Possible complications include:

• Bile leak

• Bleeding

• Bile duct injury

• Subhepatic collection

• Conversion to open surgery

Careful technique and preoperative planning reduce these risks.

Advantages of Laparoscopic Approach

• Less postoperative pain

• Faster recovery

• Shorter hospital stay

• Better cosmetic outcome

• Magnified visualization helpful in redo surgery

Prevention of Stump Cholecystitis

• Complete stone clearance during first surgery

• Proper stump closure

• Mucosal cauterization of remnant

• Achieving critical view of safety

Conclusion

Laparoscopic cholecystectomy for stump cholecystitis is a technically demanding but safe and effective procedure in experienced hands. With proper patient selection, detailed preoperative imaging, and meticulous surgical technique, excellent outcomes can be achieved. As laparoscopic skills and imaging modalities continue to improve, the laparoscopic approach is expected to remain the gold standard for management of gallbladder remnant pathology and stump cholecystitis.