The case report of the largest gallstone removed by LC was reported by Singh et al. which was 12.8 cm in diameter.5Few other reports have been reported for giant gallstones.6,7 We report two cases of patients with large/giant gallstones. In the first case, gallstone measured 4*3.3*3 cm and weighted 23.2 gm and in the second case, gallstone measured 5* 3*2.8 cm and weighted 24.7 gm. To the best of our knowledge, this is the only case report of large/giant gallstones reported till now in the literature in Nepal. Both cases were laparoscopically managed, and their postoperative courses were uneventful with no complications. Both patients were followed up after two weeks, where they had no active complaints.
As for demographics, gallstones are more common in women, especially during their fertile years, probably due to increased estrogen levels which may increase cholesterol in the bile and decreased gallbladder movement, resulting in gallstone formation.8Our case reports are in agreement, as both the cases are female. In terms of age, the frequency of gallstones increases with age, escalating after 40 years of age to become 4–10 times more likely.8Our first patient is 51 years old whereas the second patient is 39 years old, slightly younger than other reports. Gallstones are prevalent in developed nations, but less in the developing populations that still consume traditional diets. North Americans have the highest cholelithiasis rates, South Americans also have high prevalence, intermediate prevalence rates occur in Asians and Black Americans, and sub- Saharan Black Africans have the lowest frequencies.8 Gallstone disease is one of the common surgical problems in the Nepalese population and its prevalence was found to be 4.87%. The highest prevalence was found to be in Morang (6.45) and lowest in Achham (2.44).3
As for presentation, 60–80% of gallstones are asymptomatic frequently found during routine abdominal ultrasonography.9 Symptomatic gallstones may present as biliary pain, cholecystitis, or biliary obstruction depending on location.10In agreement, our cases presented as biliary colic. Gallstones can also present as gallstone ileus by migrating through a fistula between gallbladder and duodenum or small/large bowel especially in large gallstones causing bowel obstruction.11 Our two cases of large gallbladder stones did not exhibit migration.
Ultrasonography is the method most often used to detect cholelithiasis and cholecyctitis(90–95% specificity and sensitivity), can detect and accurately assess stone size as small as 2 mm, show thickening of the gallbladder wall, and should be routine.12 Ultrasonography has advantage e.g. lack of ionizing radiation, noninvasiveness, option of performing a bedside examination, relatively low cost and ability to evaluate adjacent organs.12 For our two patients, abdominal ultrasonography showed the size of the giant gallstones, with measurements close to the actual size found after surgery. Such accurate pre-operative assessment of a giant gallstone alerts the surgeon to any potential difficulty of the procedure and the possibility of conversion to open cholecystectomy. This allows the surgeon to be prepared and to explain the potential rates of complications to the patient.6 We were prepared in terms of surgical instruments and settings for a possible conversion to open at any point during the surgery.
Most gallstone patients remain asymptomatic and can be managed with watchful waiting.10 Asymptomatic gallstones > 3cm are at higher risk to develop gallbladder cancer and hence preventive LC is warranted.13 For symptomatic gallstones, LC has become the management of choice. For giant gallstones, some authors believe open cholecystectomy is the choice, given the technical difficulties related to the stone’s large size that could be confronted during the laparoscopic approach.14 However, in line with others, we believe that even with giant gallstones, LC performed by an experienced laparoscopic surgeon is still the best initial approach, unless technical difficulties and inability to expose the anatomy warrants conversion to open cholecystectomy.6 We used the laparoscopic approach for our patients without the need for conversion, there were no intra- or postoperative complications, and recovery was uneventful.
Giant gallstones could cause result in severe inflammation, adhesions, and thickening of the gallbladder wall, where adhesions are an important reason for the conversion of laparoscopic to open cholecystectomy. In addition, giant gallstones make it difficult to grasp the gallbladder with laparoscopic instruments and expose the anatomy of Calot’s triangle.15 We faced the same difficulties in our two cases, where the main challenge was to release the adhesions between the gallbladder and surrounding structures and to hold the thickened and inflamed gallbladder wall by the laparoscopic grasper before starting dissection.
Another consideration is the size and manner of retrieval of the gallbladder out of the abdomen after cholecystectomy. A recent systematic review of umbilical vs epigastric port retrieval showed that umbilical port retrieval may be associated with less post-operative pain in patients undergoing LC compared with epigastric port retrieval, and might also be associated with shorter gallbladder retrieval time.16 We retrieved the gallbladder through the umbilical approach in both cases, after infraumbilical extension of the wound. There was no delay in retrieval time, patients had mild tolerated post-operative pain and no wound infection. In terms of the manner of retrieval, for our cases, the gallbladder was put in an endo bag before taking it out of the abdomen to prevent spillage of bile or wound infection, in line with a recent meta-analysis that found that the wound infection rate was less in patients who underwent retrieval of the gallbladder using a bag vs without (4.2% vs % 5.9%)17
This case report has limitations. Information on the composition of the each of stones would have been beneficial for the better understanding of the pathophysiology. Despite this, this case report has strengths, as to the best of our knowledge, this is the only case report of large/giant gallstone reported till now in literature from Nepal.