Hartmann’s pouch stones and laparoscopic cholecystectomy: The challenges and the solutions

Abstract

Background & Objective: Hartmann’s pouch stones (HPS) encountered during laparoscopic cholecystectomy (LC) may hinder safe dissection of the cystic pedicle or be complicated by mucocele, empyema, or Mirizzi syn-drome; distorting the anatomy and increasing the risk of bile duct injury. We studied the incidence, presentations, operative challenges, and outcomes of HPS. Methods: A cohort study of a prospectively maintained database of LCs and bile duct explorations performed by a single surgeon. Patients were divided into two groups: those with HPS and those without. Patients’ demograph-ics, clinical presentation, intra-operative findings, and postoperative outcomes were compared. Results: Of the 5136 patients, 612 (11.9%) had HPS. The HPS group were more likely to present with acute chole-cystitis (27.9% vs 5.9%, P =.000) and more patients underwent emergency LC (50.7% vs 41.5%, P =.000). The HPS group had more difficult cholecystectomies, with 46.1% vs 11.8% in the non-HPS group being operative difficulty grade 4 and 5. Mucocele, empyema, and Mirizzi syndrome were more common in the HPS group (24.0% vs 3.7% P =.000, 30.9% vs 3.7% P =.000, 1.8% vs 0.9% P =.000, respectively). There was no significant differ-ence in the open conversion rate or complications. Conclusion: HPS increase the difficulty of LC. Surgeons should be aware of their presence and should employ ap- propriate dissection strategies. Sharp or diathermy dissection should be avoided. Dislodging the stone into the gall blad-der, stone removal, swab dissection, and cholangiography are useful measures to avoid ductal injury and reduce the conversion rate.