A b d o m i n a l I m a g i n g • R ev i ew

Thurley and Dhingsa

Imaging After Laparoscopic Cholecystectomy

Abdominal Imaging
Review
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Laparoscopic Cholecystectomy:
Postoperative Imaging
Peter D. Thurley 1 OBJECTIVE. The purpose of this article is to describe the imaging findings after lapa­
Rajpal Dhingsa roscopic cholecystectomy, including the normal postoperative findings and the typical ap­
pearances of major complications. The relative merits of the imaging techniques available are
Thurley PD, Dhingsa R discussed.
CONCLUsION. Laparoscopic cholecystectomy is a commonly performed surgical pro­
cedure and radiologists are often called on to identify or rule out postoperative complications.
In such cases, the correct diagnosis is crucial in optimizing patient management.

Keywords: cholelithiasis, complications, laparoscopic
cholecystectomy, normal findings
DOI:10.2214/AJR.07.3485
Received December 2, 2007; accepted after revision
March 14, 2008.
1 pancreatography (MRCP), and radionuclide
Both authors: Department of Radiology, Nottingham
University Hospitals, Queens Medical Centre, Derby Rd.,
Nottingham, NG7 2UH, United Kingdom. Address
correspondence to P. D. Thurley (pthurley@doctors.org.uk).
CME
This article is available for CME credit.
See www.arrs.org for more information.
AJR 2008; 191:794–801
0361–803X/08/1913–794
© American Roentgen Ray Society
L
aparoscopic cholecystectomy was
first developed in Europe in the
mid 1980s as an alternative to
open cholecystectomy, a proce­
dure that had been performed for more than
a century. It has rapidly gained widespread
popularity to become the procedure of choice
for patients with symp­tomatic cholelithiasis
[1]. Laparoscopic cholecystectomy has ad­
vantages over open cholecystectomy, in­
cluding a shorter hospital stay and an earlier
return to normal activities [2]. However,
complications after laparo­scopic proce­dures,
especially bile duct injuries, have been report­
ed to be more common [3], especially in the
hands of less experienced surgeons [4]. A
variety of other problems, including vascular
injury, retained gallstones, and abscess for­
mation, may also be encountered after laparo­
scopic cholecystectomy [3, 5–11] (Table 1).
The correct use of radiologic tests can
establish the type and site of postoperative
complications, allowing timely intervention
[12]. Sonography, CT, ERCP, MR cholangio­
imaging all have a role to play in evaluating
the postoperative patient [13, 14]. These invest­
igations are often complementary and the
primary imaging technique to be used will vary
depending on the clinical problem faced. It is
therefore important that radiol­ogists are aware
of the relative benefits of each investigation.
The aim of this article is to show the
spectrum of imaging findings after laparo­
scopic chole­cyst­ectomy and provide examples
of complications and normal findings. We
also discuss the advan­tages and disadvantages
of the available radiologic investigations.
Normal Appearances After
Laparoscopic Cholecystectomy
Recognizing complications after laparo­
scopic cholecystectomy as soon as possible
is advantageous because doing so allows
prompt intervention and in turn may lead to
an improved patient outcome [15]. To achieve
this, a low threshold for requesting imaging
studies is necessary, which is likely to result
in many imaging studies that simply show
the normal sequelae of laparoscopic chole­
cystectomy. The significance of imaging
findings may vary considerably depending
on the clinical findings; and it is important,
as always, to interpret the imaging in the
context of the patient’s history, examination,
and other test results.
Imaging studies may be required to look
for evidence of biloma, abscess collections,
or hematomas. However, not all fluid collec­
tions require intervention. A small amount of
fluid in the surgical bed is commonly seen
postoperatively on sono­graphy [16], which in
isolation does not justify percutaneous drain­
age. A small series that examined the CT ap­
pearances in un­complicated laparoscopic
cholecystectomy in six patients also found
that 3–5 days after surgery fluid-density ma­
terial is often seen in the gallbladder fossa
(Fig. 1). Small amounts of free pelvic fluid
and increased density in the abdominal wall
fat at the site of the laparoscopic ports were
also often present [17].

794 AJR:191, September 2008

 Imaging After Laparoscopic Cholecystectomy
TABLE 1:  Common Complications of Laparoscopic Cholecystectomy and Their Incidence
Complication
Vascular Injury
Study Bile Duct Injury or Hemorrhagea Abscessa Retained Gallstone
Hobbs et al., 2006 (n = 19,414) [4] 0.26 — — — —
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Deziel et al., 1993 (n = 77,604) [5] 0.6 0.25 — —
Azurin et al., 1995 (n = 1,300) [6] — — — —
Wherry et al., 1996 (n = 9,054) [7] 0.41 0.11 0.14 — 0.32
Shea et al., 1996 [8] — 1.05 (n = 15,596) — 0.81 (n = 6,950)
Richardson et al., 1996 (n = 5,913) [9] 0.6 — — — —
Z’graggen et al., 1998 (n = 10,174) [10] 0.31 1.97b, 0.69c 0.3 5.71
Hjelmqvist, 2000 (n = 11,164) [11] — 0.7 — —
Note—Data are percentages of patients. Dash (—) indicates information not provided.
aIntraabdominal.
bIntraoperative.
cPostoperative.
Biliary dilatation may be seen post­ 1). Surgicel (oxidized regenerated cellu­lose,
operatively due to obstruction from retained Johnson & Johnson Ethicon) is a bio­absorb­
stones or accidental clipping of bile able hemostatic agent with bactericidal prop­
ducts. However, after laparoscopic chole­ erties that is used in laparoscopic chole­
cystectomy, bile duct dilatation has also been cystectomy and other surgical procedures to
described in the absence of obstruction [18]. control hemorrhage. When imaging is per­
Furthermore, patients with cholelithiasis may formed on postoperative patients, the ap­
have had bile duct calculi preoperatively, and pearances of Surgicel can mimic those of
the resulting biliary dilatation may persist hematoma [20], abscess [21, 22], or even tu­
despite relief of the obstruction [19]. These mor [23], although Surgicel can usually be
factors should be considered when assessing differentiated from a retained surgical swab
the postoperative patient with dilated bile because of the radiopaque marker incorpo­
ducts, and correlation with biochemical rated into the latter [24]. Failure to correctly
and clinical features is important before identify Surgicel can result in patients under­
considering further investigation. going un­necessary surgery [25].
Another potential pitfall is the use of he­ The CT appearance of Surgicel is similar
mostatic agents in the gallbladder bed (Fig. to that of an infected hematoma—that is,
A B
Fig. 1—Normal appearances after cholecystectomy.
A, CT scan of 53-year-old woman 2 days after laparoscopic cholecystectomy shows collection measuring 21
HU (consistent with fluid) is present within gallbladder fossa (arrow) adjacent to cholecystectomy clip. This is
commonly seen after uncomplicated laparoscopic cholecystectomy.
B, CT scan of 62-year-old woman with abdominal pain and pyrexia after laparoscopic cholecystectomy shows
mixed gas–fluid attenuation in gallbladder fossa, consistent with Surgicel (oxidized regenerated cellulose,
Johnson & Johnson Ethicon) (arrow). Review of surgical notes confirmed that Surgicel had been used in
gallbladder bed. Patient’s symptoms settled without intervention.
AJR:191, September 2008 795
Bowel Bile Leak or Biliary Port Site
Injury Peritonitis Hernia
0.63 —
0.14 0.3 —
— — 0.77
0.53 —
0.35 (n = 5,373) 0.63 (n = 18,168) —
— —
— 0.9 —
— 0.7 —
a mass of 40–55 HU containing foci of air
[26]. Similar problems are encountered using
sonography, on which the Surgicel appears as
an echogenic mass with posterior reverberation
artifact. These sonographic ap­pearances would
be accounted for by a gas-containing abscess
[27]. MRI can be useful in differentiating
between abscess (Fig. 2) and Surgicel because
of the low signal on T2-weighted images of
the latter, possibly secondary to the imaging
characteristics of blood degradation products
[28]. Although this might prove to be a useful
problem-solving tool, good communication
between surgeons and radiologists and
correlation between imaging findings and the
clinical history, examination, and operative
findings are essential.
Fig. 2—T2-weighted MR image of 16-year-old
girl with abdominal pain, elevated inflammatory
markers, and pyrexia 2 months after laparoscopic
cholecystectomy. Note fluid collection in gallbladder
fossa (arrowhead); area of signal void anterior (arrow)
to collection represents air. Patient was treated
for infected collection with antibiotics, and MRI 6
months later showed resolution of changes.
 Thurley and Dhingsa
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A B C
Fig. 3—Bile duct injuries.
A and B, 42-year-old woman with abdominal pain, pyrexia, and leukocytosis 10 days after laparoscopic cholecystectomy. CT scan (A) shows Surgicel (oxidized
regenerated cellulose, Johnson & Johnson Ethicon) in gallbladder fossa (thin arrow, A) and small fluid collection adjacent to tip of liver (thick arrow, A). Patient underwent
laparotomy, which showed leak from common bile duct (CBD), which was sutured. Patient remained unwell and underwent ERCP (B), which showed persistent leak from
damaged CBD (arrow, B). Leak resolved after endoscopic placement of a stent.
C, Image from ERCP in 31-year-old woman. Clips have been placed across CBD (thin arrow), and free contrast material (thick arrow) is visible because of duct injury.
Patient was treated with hepatojejunostomy.

Biliary Complications
Biliary complications are more common
after laparoscopic than after open chole­
cystectomy [29] and include bile duct damage,
biliary obstruction, and dropped stones.
Bile Duct Injury
Injury to the bile ducts often goes un­
recognized at the time of surgery [30]. There
should be a high level of suspicion when
patients are referred with symptoms of ab­
dom­inal pain, sepsis, or jaundice soon
after laparoscopic cholecystectomy [31].
The reported rate of bile duct injury after
laparoscopic cholecystectomy varies among
different series; however, a review of 5,913
cases over a 5-year period showed a 0.6%
overall rate of bile duct injury, with the rate
for individual surgeons ranging from 0.4% to
4% [9].
Initial assessment in patients with sus­
pected bile duct injury is usually with sono­
graphy or CT [32]. These investigations may
show perihepatic fluid collections (Figs. 3
and 4), although the absence of these does
not exclude injury [33]. Free intraperitoneal
fluid may also be seen, although this is a non­
specific finding in a postoperative patient
[34]. Hepatobiliary scintigraphy is a less
commonly used non­invasive method of eval­
uating patients with suspected bile duct in­
jury that has two potential advantages over
sonography and CT. First, it has been claimed
to be more sensitive and specific than sono­
graphy or CT in detecting bile leaks [35].
Second, as well as confirming a bile leak, he­
patobiliary scintigraphy may identify the re­
lationship between the leak and the collec­
tion [36] and show the primary route of bile
flow [35]. Despite this, it may be necessary
to complement scintigraphy with other inves­
tigations such as ERCP to fully appreciate
the degree of bile duct injury [37].
Although it is an invasive procedure,
ERCP is useful in patients in whom there is

A B C
Fig. 4—56-year-old woman with abdominal pain following laparoscopic cholecystectomy.
A, CT scan shows multiple large intraabdominal fluid collections (arrows) that contained bile when drained.
B, Subsequent ERCP shows leak from cystic duct stump (arrow).
C, Subsequent ERCP shows stent that has been deployed endoscopically in common bile duct across origin of cystic duct.

796 AJR:191, September 2008

 Imaging After Laparoscopic Cholecystectomy

a strong suspicion of bile duct injury (Fig.
3). As well as being able to show the exact
site of injury or leak, ERCP can sometimes
be used to successfully treat the leak using
internal stents (Fig. 4). Success using this
technique may be more likely if the injury to
the duct is < 5 mm, the injury is extrahepatic,
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[42]. As discussed previously, the presence
of dilated ducts alone is not diagnostic of
biliary obstruction. Stones may be identified
on sonography if good views of the biliary
tree can be obtained or on CT if the stones
are of a differing density from bile. If CT or
sonography does not clearly delineate a cause
has previously been highlighted as a prob­
lematic area. An editorial reviewing ways of
minimizing complications of laparoscopic
surgery suggested that unless a surgeon is
competent at recognizing gross changes on
cholangio­graphy, he or she should not per­
form laparo­scopic cholecystectomies [48].

and there is no associated abscess or biloma
[38]. Open surgery is the main alternative
to ERCP in cases of persistent leaks; some
authors have recommended ERCP as the first-
line treatment for such patients in an effort
to avoid the increased morbidity associated
with open surgery [34].
MRCP is an alternative way of assessing
the anatomy of bile ducts. The use of
mangafodipir trisodium, a contrast agent that
is primarily excreted via bile, makes it
possible to both diagnose a bile leak and
identify the source of the leak [39, 40]. The
advantages of this technique are that it is
noninvasive and does not use ionizing
radiation; however it has limitations,
including poor opacification of bile ducts in
the presence of obstruction and unreliable
depiction of the more peripheral intrahepatic
bile ducts [39].
Biliary Obstruction
Causes of biliary obstruction include
retain­ed gallstones (Fig. 5), misplaced surg­
ical clips, fibrosis secondary to in­flammation
from adjacent clips, and thermal injury from
cautery devices [38]. Although typically
obstruction at the level of the common bile
duct produces intrahepatic duct dilatation in
both lobes [41], dilatation in a single lobe, most
commonly the left (Fig. 6), may also occur
for the obstruction, MRCP can identify stones
as small as 2 mm that are retained in the
biliary tree [43]. Identification of these stones
allows planning of management strategies
for patients who may require inter­vention
with ERCP. Alternatively, if imaging shows
no obstruction or retained stones, ERCP,
which is an invasive and potentially harmful
investigation [44], can be avoided.
Intraoperative cholangiography (IOC) can
allow surgeons to identify stones in the bile
ducts (Fig. 7) and also help to correctly iden­
tify the anatomy of the biliary tree, thereby
preventing division of structures other than
the cystic duct [45]. The role of IOC is con­
troversial, with some surgeons advocating
its use in all patients undergoing laparoscop­
ic cholecystectomy and others reserving
IOC for patients with a high risk of bile
duct injury—such as patients with atypical
anatomy—or retained gallstones [46]. It has
been shown that, even if IOC is performed,
bile duct injury may go undiagnosed at the
time of surgery. In a study of 64 patients who
had sustained a bile duct injury at laparo­
scopic cholecystectomy 39 underwent IOC.
Of those 39, the injury was recognized in
only 33% at the time of the operation. In ret­
rospect, a further 29% had evidence of bile
duct injury on IOC images [47]. The failure
to correctly identify abnormalities on IOC
However, as previously stated, opinion is di­
vided, with some authors claiming there is
no evidence that IOC prevents injury and is
an additional burden in terms of both time
and money [49].
Dropped Gallstones
Spillage of gallstones occurs commonly
during laparoscopic cholecystectomy, with a
reported incidence of 0.1–20% [50]. Fortu­
nately, most of these stones do not cause
symptoms [46], although if spillage does oc­
cur every effort should be made to retrieve
the stones in view of the small risk of devel­
oping important complications [51]. The
most common complication reported in the
literature is abscess, either in the abdominal
wall or in the peritoneum [52]. Retained
gallstones have also presented after erosion
through the skin [53], as a colovesical fistula
[54], with expectoration of stones (chole­
lithoptysis) [55], and as the cause of an incar­
cerated hernia [56].
Dropped gallstones leading to abscess
formation can occur after a period of months
to years after the laparoscopic cholecystec­
tomy, which can make diagnosis challenging
[57]. Spilled gallstones appear on sonogra­
phy as small hyperechoic lesions that may be
related to fluid collections and are found
most often in the subdiaphragmatic or sub­

A B C
Fig. 5—56-year-old woman with abdominal pain 3 months after laparoscopic cholecystectomy.
A, Axial CT image shows low-attenuation change in pancreas (arrow) and peripancreatic fluid, in keeping with pancreatitis.
B, MRCP shows filling defects in common bile duct (CBD) (arrows) and normal-caliber pancreatic duct (arrowheads).
C, ERCP confirms retained gallstones in CBD (arrow).

AJR:191, September 2008 797

 Thurley and Dhingsa

chronic or recurrent cholecystitis [66].

Hepatic artery pseudoaneurysm formation
(Fig. 9) has also been described after
laparoscopic cholecystectomy and may be
related to bile leak and subsequent infection
[67]. If this occurs, contrast-enhanced CT
may show a hematoma or directly show the
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pseudoaneurysm. Imaging with selective

angiography of the celiac and superior
mesenteric arteries is helpful in confirming
the diagnosis [68] and facilitates subsequent
endovascular treatment.

Other Complications
Several less common complications of
A B
laparoscopic cholecystectomy have been re­
Fig. 6—72-year-old man with abdominal pain and abnormal liver biochemistry following laparoscopic ported that may be diagnosed radiologically.
cholecystectomy.
A, Postoperative CT scan shows dilated ducts in left lobe of liver.
The incidence of port site hernia after lap­
B, ERCP shows filling defects in common bile duct that are consistent with retained stones. Gallstones were aroscopic surgery (Fig. 10) is estimated to
subsequently removed endoscopically. be 0.02–3.6% [69] and may cause small-
bowel obstruction. Although hernias are of­
hepatic spaces [58] (Fig. 8). If they are calci­ because of small vessels in the abdominal ten suspected clinically because of a palpa­
fied, gallstones may also be visible on CT as wall, most commonly the inferior epi­gastric ble lump at a port site, the diagnosis can be
hyperdense areas or on T1-weighted MRI as vessels [61] or mesentery [62], or larger ves­ confirmed using CT [70]. Diaphragmatic
a signal void [59]. sels such as the inferior vena cava and aorta hernias are more rare and can also be diag­
[63]. Abdominal wall and intra­peri­ton­eal nosed with the aid of CT by revealing a de­
Vascular Complications hematomas can be readily visualized on fect in the diaphragm or herniation of peri­
Vascular injuries during laparoscopic chole­ CT as areas of higher atten­uation. On sono­ toneal fat into the chest [71]. In addition,
cystectomy most commonly occur in the graphy, hema­tomas appear as heterogeneous cases of portal vein thrombosis diagnosed
surgical bed or the abdominal wall and are fluid collections [64]. on sonography [72], splenic rupture diag­
related to trocar insertion [46]. A review of During the dissection of structures in the nosed on CT [73], intestinal ischemia [74],
14,243 laparoscopic procedures showed an gallbladder bed, the right hepatic artery is the and delayed bowel perforation due to ther­
overall hemorrhage rate of 4.1%, with bleeding vessel most commonly injured, followed by mal injury [75] have all been reported after
rates of 2.3% intraoperatively and 1.8% the portal vein [65]. Life-threatening bleeding laparoscopic cholecystectomy.
postoperatively [60], although the reported can occur from the gallbladder bed without
incidence varies among series [5, 7, 8, 10, 11]. obvious major vessel injury, especially in Summary
Trocar insertion at the beginning of a patients with preexisting liver disease such Laparoscopic cholecystectomy has an
laparo­scopic procedure may cause bleeding as steatosis hepatis, hepatic siderosis, and overall complication rate of approximately

A B
Fig. 7—Intraoperative cholangiography image of Fig. 8—71-year-old man with history of laparoscopic cholecystectomy.
66-year-old woman shows stone at distal common A, Sonogram shows dropped gallstone in subdiaphragmatic space (arrow).
bile duct (arrow) and bile duct dilatation. B, Reformatted oblique coronal CT image shows subdiaphragmatic gallstone (arrow).

798 AJR:191, September 2008

 Imaging After Laparoscopic Cholecystectomy

Fig. 9—41-year-old woman 3 weeks after

laparoscopic cholecystectomy. Patient presented
with abdominal pain. (Courtesy of R. O’Neill,
Nottingham University Hospitals.)
A and B, CT scans show area of hyperdensity
representing contrast material (arrow) and
associated area of mixed attenuation suspected to
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be a hematoma. This raised possibility of hemorrhage

from a pseudoaneurysm. Note adjacent surgical clip
(arrowhead).
C and D, Diagnosis of hepatic artery pseudo­
aneurysm (arrow, D) was confirmed with selective
angiography of celiac axis. Note adjacent surgical
clip (arrowhead, D).
A B

C D

puts patients at risk of undergoing un­
necessary and invasive procedures.
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