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.

Although ERCP is generally successful, some complications may arise. These complications may include:

• Pancreatitis: Pancreatitis is one of the most common complications of ERCP. It involves inflammation of the pancreas and can cause symptoms such as pain, nausea, and vomiting.
• Bleeding: Bleeding may occur during or after the procedure due to damage to the bile ducts or pancreas.
• Infection: Infection may develop during or after the use of the endoscope.
• Bile leakage: Bile leakage may occur due to damage to the bile ducts during the use of the endoscope.

When gallbladder surgery is required after ERCP, the surgery itself carries risks. These risks include infection, bleeding, injury to the bile ducts or neighboring organs, bile leakage, and complications related to anesthesia.

However, both procedures are generally successful when performed by an experienced surgeon. Risks can vary depending on factors such as the patient’s overall health, age, accompanying health problems, and the experience of the surgical team.