In patients experiencing issues related to gallstones, the gold standard treatment is cholecystectomy (removal of the gallbladder). The ideal outcome of this surgery is the COMPLETE removal of the gallbladder. But what if, even though complete removal is intended, a portion of the gallbladder remains?

Interestingly, the occurrence of the gallbladder not being completely removed, which was rarely seen during open cholecystectomy, is reported more frequently after laparoscopic cholecystectomy.

This poses an interesting issue considering the numerous advantages of laparoscopic surgery. Leaving the base of the gallbladder or an excessively long cystic duct during surgery can lead to unresolved or recurring symptoms for patients. In patients who have undergone cholecystectomy with the gallbladder partially remaining, symptoms such as abdominal pain, indigestion, nausea, and even jaundice can occur. Additionally, cholangitis (inflammation of the bile ducts) or pancreatitis (inflammation of the pancreas) may develop. These symptoms may result from remaining gallstones or the development of new ones over time.

The incomplete removal of the gallbladder during laparoscopic cholecystectomy has been reported in about 13% of cases. In other words, in about one out of every 7-8 patients who undergo gallbladder surgery, the gallbladder may not be completely removed. Several risk factors have been identified for this occurrence, including:

• Inadequate exposure of the gallbladder bed during surgery,
• Severe adhesions due to previous surgery or inflammation,
• Active inflammation of the gallbladder (acute cholecystitis),
• Excessive bleeding during surgery impairing visibility,
• Congenital anomalies of the gallbladder,
• Changes in anatomy due to lesions developing in the gallbladder over time.

In patients who continue to experience symptoms despite gallbladder surgery, the only issue may not be the presence of a remnant gallbladder portion. Specific tests should be conducted to confirm or rule out this possibility. While blood tests and ultrasound may be initial investigations, in many patients, magnetic resonance cholangiography (MRCP), a type of MRI examination of the bile ducts, provides a definitive diagnosis. In some cases, diagnosis occurs during endoscopic retrograde cholangiopancreatography (ERCP), an endoscopic procedure for the bile ducts.

If appropriate investigations reveal no residual stump or stones, other causes of symptoms should be explored. However, if a remnant gallbladder or a stone within a long cystic duct is detected, intervention is often necessary. These interventions may involve endoscopic methods or, in some cases, require open or laparoscopic reoperation. As expected, reoperation carries risks of bile duct injury, vascular injury, or injury to other organs.

Although with increasing experience, the likelihood of incomplete removal of the gallbladder is considered lower, its clinical significance remains a significant concern. Just as in any surgery, having profound anatomical knowledge and extensive experience with challenging cases are crucial for ensuring complete gallbladder removal and minimizing such issues.