Description

Stump cholecystitis is a rare but important clinical entity that occurs after a subtotal cholecystectomy, when a remnant of the gallbladder or cystic duct is left behind. This residual portion may later become inflamed or harbor calculi, leading to recurrent biliary symptoms. Patients may present with right upper quadrant pain, dyspepsia, nausea, or jaundice, often mimicking primary gallbladder disease. With advances in minimally invasive surgery, laparoscopic cholecystectomy of the gallbladder stump has become a safe and effective treatment option. Etiology and Pathophysiology Residual Gallbladder Remnant: During difficult cholecystectomies, especially in cases with severe inflammation, subtotal cholecystectomy may be performed to avoid bile duct injury. Stone Formation: The remnant may act as a nidus for stone formation, leading to recurrent attacks. Mucosal Inflammation: Retained mucosa in the stump continues to secrete mucus and bile, causing stasis and recurrent infection. Cystic Duct Calculi: Stones in the cystic duct stump are a major cause of post-cholecystectomy syndrome. Clinical Presentation Patients with stump cholecystitis often present with: Right hypochondriac or epigastric pain Fever and leukocytosis (during acute episodes) Dyspepsia and bloating Jaundice if there is associated choledocholithiasis Diagnosis Ultrasonography (USG): First-line investigation; may reveal residual stump and calculi. MRCP (Magnetic Resonance Cholangiopancreatography): Gold standard for evaluating biliary anatomy and detecting stones in the remnant or common bile duct. CT Scan: Useful in complicated cases or when MRCP is inconclusive. ERCP: Both diagnostic and therapeutic if choledocholithiasis coexists. Laparoscopic Management Laparoscopic completion cholecystectomy is considered the treatment of choice for stump cholecystitis. Surgical Steps: Port Placement: Standard four-port laparoscopic approach. Adhesiolysis: Extensive adhesions are often present due to previous surgery and chronic inflammation. Careful dissection is essential. Identification of the Stump: The gallbladder remnant or cystic duct stump is dissected meticulously. Securing the Cystic Duct: The remnant cystic duct is skeletonized and clipped or ligated. Removal of Stump and Stones: The gallbladder stump with calculi is excised completely. Inspection of CBD: Intraoperative cholangiography or choledochoscopy may be performed if suspicion of CBD stones exists. Challenges in Surgery Dense adhesions around Calot’s triangle Altered anatomy due to previous dissection Risk of bile duct injury Difficulty in localizing the remnant gallbladder Experienced laparoscopic surgeons and advanced energy devices play a key role in reducing complications. In some cases, conversion to open surgery may be necessary for patient safety. Advantages of Laparoscopic Completion Cholecystectomy Minimally invasive with faster recovery Reduced postoperative pain Shorter hospital stay Excellent long-term results with resolution of symptoms Conclusion Stump cholecystitis is an uncommon but significant cause of recurrent biliary symptoms after cholecystectomy. With precise preoperative imaging and careful surgical planning, laparoscopic completion cholecystectomy offers a safe and definitive cure. Surgeons must be vigilant about biliary anatomy and prepared for complex adhesiolysis, ensuring both safety and efficacy of the procedure.