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From the question on page 617

The patient had a 7–10 mm calculus, presumed to have “escaped” during her laparoscopic cholecystectomy, as demonstrated by the ultrasonographic shadow cast (fig 1, below). Drainage and antibiotic treatment caused cessation of symptoms, only to recur shortly after discharge from hospital. Encapsulation probably prevented antibiotic penetration of the abscess. The calculus was subsequently removed laparoscopically, as shown in the videos (see supplementary files) and figs 1 and 2), and the patient has remained well since.

Figure 1

Ultrasound scan showing collection.

Figure 2

Calculus during laparoscopy.

Approximately 7% of patients may have residual stones left in the abdomen since approximately 15–20% of laparoscopic cholecystectomies result in splitting of the gallbladder, with 40% of these resulting in stones falling out.1 Lost stones were traditionally considered inconsequential but a number of animal models and case reports have clearly demonstrated that there are a variety of different complications from this including sepsis (intra-/extra-abdominal), pain and effusions. The rate of complications from these stones has been put at 1.7 per 1000 laparoscopic cholecystectomies.2 Unusually, the calculus here has precipitated symptoms 4 years later. Following its successful retrieval, there should be no further complications.

Figure 3

Calculus after removal.

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