249 Laparoscopic Assisted Enterolithotomy: A Viable Option in The Management of Gallstone Ileus

Abstract

Abstract Introduction Gallstone ileus (GSI) is a rare cause of small bowel obstruction in patients over the age of 65 years. We report a case of GSI treated successfully with a laparoscopic assisted enterolithotomy. Case report A 75-year-old female presented with two days of abdominal distension and vomiting with a non-peritonitic abdomen on examination. A computerised tomography scan demonstrated small bowel obstruction due to an obstructing stone in the distal ileum. Three port laparoscopy and small bowel assessment confirmed a solitary enterolith (4cms) in the distal ileum with upstream dilated loops. An infra-umbilical 6 cm midline incision was made and the localised bowel loop was delivered. An enterotomy was made proximal to the point of obstruction, stone retrieved, and a single layer interrupted closure was performed. Ten weeks post-operatively, patient had a virtual follow-up consultation and is doing well. Conclusions GSI often presents in elderly patients with multiple co-morbidities. A laparotomy with enterolithotomy is the initial treatment of choice with biliary intervention as a second operation, if needed, at a later date. Clearly, a conventional exploratory laparotomy in this cohort of patients carries a high risk and therefore the use of less morbid and less invasive procedure like laparoscopy should be considered. Although a total laparoscopic approach would require advanced laparoscopic skills particularly due to dilated bowel loops limiting the intra-abdominal space for suturing, a laparoscopic assisted approach as described above should be considered as a reasonable option within the remits of an emergency general surgeon.