Case Report: Multiple complications after laparoscopic cholecystectomy with perforation and spilled gallstones

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However, it may result in stone spilling, which potentially can lead to serious postoperative complications. Case report A 70-year-old male underwent laparoscopic cholecystectomy for acute cholecystitis. The procedure was complicated by perforation of the gallbladder and spilling of gallstones. More than a year after the procedure, the patient developed subcutaneous abscesses containing some of the spilled stones, a computed tomography revealed a complex intraabdominal and intrathoracic fistula with communication from the abdominal cavity to pleura and ultrasonic imaging found a lost gallstone in the thorax. After two years, the patient developed pleural empyema and sepsis secondary to the condition. Presently, the patient awaits surgery for the fistula and empyema. Conclusion Proper care should be taken to avoid stone spilling during laparoscopic cholecystectomy. However, if perforation and stone spilling occur, all visible stones should be removed during the procedure and the complication should be noted in the medical records. Furthermore, the patient should be thoroughly informed. This may help accelerate diagnosis if the patient later suffers from a complication related to lost stones. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/5-2322/v2", "name": "Case Report: Multiple complications after laparoscopic cholecystectomy..." } } ] } Home Browse Case Report: Multiple complications after laparoscopic cholecystectomy... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Klubien J, Borgersen DW, Rosenberg J and Pommergaard HC. Case Report: Multiple complications after laparoscopic cholecystectomy with perforation and spilled gallstones [version 2; peer review: 2 approved with reservations] . F1000Research 2026, 5 :2322 ( https://doi.org/10.12688/f1000research.9490.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Revised Case Report: Multiple complications after laparoscopic cholecystectomy with perforation and spilled gallstones [version 2; peer review: 2 approved with reservations] Jeanett Klubien 1,2 , Dorte Winther Borgersen 3 , Jacob Rosenberg https://orcid.org/0000-0002-0063-1086 1,2 , Hans-Christian Pommergaard 4 Jeanett Klubien 1,2 , Dorte Winther Borgersen 3 , Jacob Rosenberg https://orcid.org/0000-0002-0063-1086 1,2 , Hans-Christian Pommergaard 4 PUBLISHED 13 May 2026 Author details Author details 1 Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev, Denmark 2 Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark 3 Department of Surgery, Herlev Hospital, Herlev, Denmark 4 Department of Surgery, Hvidovre Hospital, Hvidore, Denmark Jeanett Klubien Roles: Investigation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Dorte Winther Borgersen Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Jacob Rosenberg Roles: Conceptualization, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Hans-Christian Pommergaard Roles: Conceptualization, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Abstract Introduction Perforation of the gallbladder is a benign and common complication during laparoscopic cholecystectomy. However, it may result in stone spilling, which potentially can lead to serious postoperative complications. Case report A 70-year-old male underwent laparoscopic cholecystectomy for acute cholecystitis. The procedure was complicated by perforation of the gallbladder and spilling of gallstones. More than a year after the procedure, the patient developed subcutaneous abscesses containing some of the spilled stones, a computed tomography revealed a complex intraabdominal and intrathoracic fistula with communication from the abdominal cavity to pleura and ultrasonic imaging found a lost gallstone in the thorax. After two years, the patient developed pleural empyema and sepsis secondary to the condition. Presently, the patient awaits surgery for the fistula and empyema. Conclusion Proper care should be taken to avoid stone spilling during laparoscopic cholecystectomy. However, if perforation and stone spilling occur, all visible stones should be removed during the procedure and the complication should be noted in the medical records. Furthermore, the patient should be thoroughly informed. This may help accelerate diagnosis if the patient later suffers from a complication related to lost stones. READ ALL READ LESS Keywords Laparoscopic cholecystectomy, spilled gallstones, lost gallstones, abscess, fistula, empyema, case report Corresponding Author(s) Jeanett Klubien ( [email protected] ) Close Corresponding author: Jeanett Klubien Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2026 Klubien J et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Klubien J, Borgersen DW, Rosenberg J and Pommergaard HC. Case Report: Multiple complications after laparoscopic cholecystectomy with perforation and spilled gallstones [version 2; peer review: 2 approved with reservations] . F1000Research 2026, 5 :2322 ( https://doi.org/10.12688/f1000research.9490.2 ) First published: 14 Sep 2016, 5 :2322 ( https://doi.org/10.12688/f1000research.9490.1 ) Latest published: 13 May 2026, 5 :2322 ( https://doi.org/10.12688/f1000research.9490.2 ) Revised Amendments from Version 1 The following sentences were added after review (case report section): Lastly, the peritoneal cavity was irrigated with saline to retrieve any additional gallstones. Additional information regarding bacterial culture or antibiotic treatment were, unfortunately, not retrieved from the patient's medical record. The following sentences were added after review (case report section): Lastly, the peritoneal cavity was irrigated with saline to retrieve any additional gallstones. Additional information regarding bacterial culture or antibiotic treatment were, unfortunately, not retrieved from the patient's medical record. See the authors' detailed response to the review by Gabriel Sandblom See the authors' detailed response to the review by Tatsuhiro Masaoka READ REVIEWER RESPONSES Introduction Perforation of the gallbladder during laparoscopic cholecystectomy (LC) is a well-known and common complication (8–40%) 1 that may lead to intraabdominal spilling of gallstones and some of the spilled stones may not be retrieved despite all efforts. The incidence of lost stones during LC is less frequent and varies in the literature from 0.1 to 20%. 1 – 3 Although considered a benign complication, it is reported that 0.03–8.5% of the lost stones will lead to a postoperative complication. 2 , 3 We present a case of multiple complications after perforation of the gallbladder and subsequent stone spilling during LC. This case report is reported according to the CARE statement. 4 Case report A 70-year-old Caucasian male, with a medical history of hypertension, was admitted in March 2014 after four days of diffuse abdominal pain and fever up to 39°C. A computed tomography (CT) scan identified multiple gallstones in an inflamed gallbladder. To verify the diagnosis, abdominal ultrasonic imaging confirmed multiple gallstones and thickening of the gallbladder wall as signs of acute cholecystitis. The patient underwent acute LC with the intraoperative finding of a severely inflamed gallbladder. In addition, the procedure was complicated by perforation of the gallbladder and gallstones were spilled. The gallbladder was removed using an endoscopic bag after complete dissection to prevent further stone spilling and all visible stones were removed. Lastly, the peritoneal cavity was irrigated with saline to retrieve any additional gallstones. The complication was noted in the medical records. One year after the procedure, the patient was admitted with tenderness in the right upper quadrant. A CT was performed and showed a swelling in the upper right part of the abdominal wall and between the liver and the lower lobe of the right lung with calcifications at both sites assumed to be lost gallstones ( Figure 1 ). The patient did not receive any treatment for the swellings. Figure 1. Timeline. An overview of the patient's hospital contacts and procedures after the laparoscopic cholecystectomy. s.c. subcutaneous, dxt. dexter, CT computed tomography, MGUS monoclonal gammopathy of undetermined significance, ATN acute tubular necrosis. During the period between 15 and 18 months following the LC, the patient returned to the hospital two times due to subcutaneous abscesses below the right rib curvature and the right side of the lower back. The suspected lost gallstones were assumed to have migrated to the subcutaneous tissue causing abscess formation. The diagnosis was confirmed by CT and compared with the previous CT ( Figure 2 ). Both abscesses were located deep in the subcutaneous tissue and due to location and size, these were treated with ultrasound-guided incision and drainage. Additional information regarding bacterial culture or antibiotic treatment were, unfortunately, not retrieved from the patient’s medical record. During these procedures, four gallstones were located and removed from the abscess cavities. Afterwards the patient was followed as an outpatient because of daily secretion from the abscess cavity on the patient’s back. Because of the unhealed abscess cavity, CT and ultrasound scans were performed 18 months after the LC. The CT revealed a complex intraabdominal and intrathoracic fistula with external opening in the lower right side of the back with communication to pleura. The ultrasonic imaging revealed a lost gallstone in the lower right side of thorax. The fistula was treated conservatively with drainage. Figure 2. Abdominal computed tomography. An abdominal computed tomography showing spilled gallstones at different levels 15 months after the laparoscopic cholecystectomy (dotted arrows). (a) Shows a gallstone behind the liver and (b) shows a gallstone in the abdominal wall. In February 2016, the patient was admitted to the hospital because he had developed sepsis and pleural empyema secondary to the condition. The patient had a short stay at the intensive care unit and was discharged from the hospital after one month. During this month, the patient developed monoclonal gammopathy and acute tubular necrosis due to the infection in the fistula. After hospitalization, the fistula was rinsed daily with saline solution and during one of these procedures another gallstone was excavated. Presently, the patient awaits surgery for the fistula and empyema. Discussion This case is an example of serious complications caused by spilled gallstones. Migration of lost stones, as in this case, can cause both local and systemic complications. However, stone spillage is unavoidable in some patients despite precautionary measures. The spilled stones may be harmless, but efforts should be made during the procedure to locate and remove all stones to prevent future local and systemic complications. The postoperative complications due to lost gallstones may develop weeks to several years after the primary procedure and are not necessarily located in the right upper quadrant. 2 , 5 , 6 Together with a lack of awareness or documentation in the medical records, this may contribute to a delayed diagnosis of a stone complication. However, delayed diagnosis may also be due to the fact that some gallstones are not visible on CT. Predisposing factors for complications of the spilled gallstones include older age, male sex, perihepatic localization of lost stones, acute cholecystitis, spilling of pigment stones compared with cholesterol stones, multiple stones (>15 stones), and large stone size (> 1.5 cm). 1 It is not mandatory to convert to open surgery for retrieving stones after perforation has occurred during LC, 3 , 6 due to a subsequent low incidence of severe postoperative complications 2 , 3 and since conversion to open surgery is associated with a higher rate of systemic complications compared with laparoscopic surgery. 3 In this case report, the surgeon chose not to convert to open surgery to look for more lost gallstones, which goes well in hand with the recommendations found in the literature. 3 , 6 However, proper care should be taken to avoid stone spilling and thereby possible postoperative complications. All visible stones should be removed during the laparoscopic procedure and the gallbladder should be retrieved in an endoscopic bag upon dissection to prevent further stone spilling when a perforation has occurred. 7 In this case, the gallstones were found on CT before complications developed. Perhaps, the abscesses and fistula could have been avoided if the stones had been removed when they were discovered. In conclusion, stone spillage is an unavoidable and well-known problem to LC. If perforation and stone spillage occur, it should be noted in the medical records and the patient should be thoroughly informed about the lost stones and their possible postoperative complications. This may help the clinicians and accelerate the diagnosis if the patient later on suffers from a complication due to lost stones. Consent Written informed consent was obtained from the patient for publication of this case report and any accompanying images and/or other details that could potentially reveal the patient’s identity. Data availability No data availability associated with the manuscript. Author contributions JK, DW, JR, and HCP conceived the study. JK and HCP prepared the first draft of the manuscript. DWB, JR and HCP did the revision and all authors have read and approved the final version of the manuscript. References 1. Brockmann JG, Kocher T, Senninger NJ, et al. :Complications due to gallstones lost during laparoscopic cholecystectomy. Surg. Endosc. 2002; 16 (8): 1226–1232. PubMed Abstract | Publisher Full Text 2. Zehetner J, Shamiyeh A, Wayand W:Lost gallstones in laparoscopic cholecystectomy: all possible complications. Am. J. Surg. 2007; 193 (1): 73–78. PubMed Abstract | Publisher Full Text 3. Schäfer M, Suter C, Klaiber C, et al. :Spilled gallstones after laparoscopic cholecystectomy. A relevant problem? A retrospective analysis of 10,174 laparoscopic cholecystectomies. Surg. Endosc. 1998; 12 (4): 305–309. PubMed Abstract | Publisher Full Text 4. Gagnier JJ, Kienle G, Altman DG, et al. :The CARE guidelines: consensus-based clinical case reporting guideline development. J. Med. Case Rep. 2013; 7 : 223. PubMed Abstract | Publisher Full Text | Free Full Text 5. Hougård K, Bergenfeldt M:Abdominal fistula 7 years after laparoscopic cholecystectomy. Ugeskr. Laeger. 2008; 170 (36): 2803. PubMed Abstract 6. Hillingsø JG, Kristiansen VB:Abscess in the right flank—a late complication of laparoscopic cholecystectomy. Ugeskr. Laeger. 1999; 161 (32): 4520–4521. PubMed Abstract 7. Demirbas BT, Gulluoglu BM, Aktan AO:Retained abdominal gallstones after laparoscopic cholecystectomy: a systematic review. Surg. Laparosc. Endosc. Percutan. Tech. 2015; 25 (2): 97–99. PubMed Abstract | Publisher Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 14 Sep 2016 ADD YOUR COMMENT Comment Author details Author details 1 Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev, Denmark 2 Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark 3 Department of Surgery, Herlev Hospital, Herlev, Denmark 4 Department of Surgery, Hvidovre Hospital, Hvidore, Denmark Jeanett Klubien Roles: Investigation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Dorte Winther Borgersen Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Jacob Rosenberg Roles: Conceptualization, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Hans-Christian Pommergaard Roles: Conceptualization, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 13 May 2026, 5:2322 https://doi.org/10.12688/f1000research.9490.2 version 1 Published: 14 Sep 2016, 5:2322 https://doi.org/10.12688/f1000research.9490.1 Copyright © 2026 Klubien J et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Klubien J, Borgersen DW, Rosenberg J and Pommergaard HC. Case Report: Multiple complications after laparoscopic cholecystectomy with perforation and spilled gallstones [version 2; peer review: 2 approved with reservations] . F1000Research 2026, 5 :2322 ( https://doi.org/10.12688/f1000research.9490.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 14 Sep 2016 Views 0 Cite How to cite this report: Masaoka T. Reviewer Report For: Case Report: Multiple complications after laparoscopic cholecystectomy with perforation and spilled gallstones [version 2; peer review: 2 approved with reservations] . F1000Research 2026, 5 :2322 ( https://doi.org/10.5256/f1000research.10221.r16707 ) The direct URL for this report is: https://f1000research.com/articles/5-2322/v1#referee-response-16707 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 10 Oct 2016 Tatsuhiro Masaoka , Department of Internal Medicine, Keio University School of Medicine, Tokyo, 160-8582, Japan Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.10221.r16707 Authors reported a case complicated with stone spillage after laparoscopic cholecystectomy (LC). Perforation of the gallbladder during LC is a common complication and the incidence of lost stones during LC is not so rare. However it is rare that lost ... Continue reading READ ALL Authors reported a case complicated with stone spillage after laparoscopic cholecystectomy (LC). Perforation of the gallbladder during LC is a common complication and the incidence of lost stones during LC is not so rare. However it is rare that lost stones lead such a severe postoperative complication. So I think this paper is very interesting. However the authors had better concern the following points. Case report session is well written. Authors summarize the long progression in compact. I would like to know at one year after procedure how do authors indicate treatment options to patients and his family. Authors described a CT just showed swelling around calcification. However the patient was conscious of abdominal tenderness, and the cause of tenderness is assumed to be lost gallstone. I think operation must be considered as the best treatment at this point. Authors should discuss more about this point. During the period between 15 and 18 months following the LC, subcutaneous abscesses were formed. The patient was treated with ultrasound-guided incision and drainage. Did authors take bacterial culture? How about antibacterial treatment? Proper antibacterial treatment is important for preventing for progression of diseases. If done, authors should mention detail antibacterial treatment such as choices, doses, duration etc. The discussion session is also well written. However authors did not mentioned fistula with communication to pleura. I would like to know why the patient developed fistula. What is the main factor of fistulization? The position of spilled gallstone? Inadequate treatment for abscess? Just after LC, did authors take CT? Of course operation for removing spilled gallstone might be best choice for preventing fistulization when the gallstone was found. Is there any other choice avoiding fistula with communication to pleura? Authors should discuss about this point. Competing Interests: No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Masaoka T. Reviewer Report For: Case Report: Multiple complications after laparoscopic cholecystectomy with perforation and spilled gallstones [version 2; peer review: 2 approved with reservations] . F1000Research 2026, 5 :2322 ( https://doi.org/10.5256/f1000research.10221.r16707 ) The direct URL for this report is: https://f1000research.com/articles/5-2322/v1#referee-response-16707 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 21 Jan 2026 Jeanett Klubien , Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev, Denmark 21 Jan 2026 Author Response Case report session is well written. Authors summarize the long progression in compact. I would like to know at one year after procedure how do authors indicate treatment ... Continue reading Case report session is well written. Authors summarize the long progression in compact. I would like to know at one year after procedure how do authors indicate treatment options to patients and his family. Authors described a CT just showed swelling around calcification. However the patient was conscious of abdominal tenderness, and the cause of tenderness is assumed to be lost gallstone. I think operation must be considered as the best treatment at this point. Authors should discuss more about this point. During the period between 15 and 18 months following the LC, subcutaneous abscesses were formed. The patient was treated with ultrasound-guided incision and drainage. Did authors take bacterial culture? How about antibacterial treatment? Proper antibacterial treatment is important for preventing for progression of diseases. If done, authors should mention detail antibacterial treatment such as choices, doses, duration etc. Response: Thank you for this thoughtful comment. Unfortunately, detailed information regarding discussions of treatment options with the patient and family is not available. Likewise, no additional data regarding bacterial cultures or antibiotic therapy were available. We agree that microbiological evaluation and appropriate antibiotic treatment are important considerations in such cases, and we acknowledge this as a limitation of the present report. The discussion session is also well written. However authors did not mentioned fistula with communication to pleura. I would like to know why the patient developed fistula. What is the main factor of fistulization? The position of spilled gallstone? Inadequate treatment for abscess? Just after LC, did authors take CT? Of course operation for removing spilled gallstone might be best choice for preventing fistulization when the gallstone was found. Is there any other choice avoiding fistula with communication to pleura? Authors should discuss about this point Response: Thank you for this comment. The exact mechanism of the fistulation remains unclear, but it might have been driven by chronic inflammation originating from the retained gallstones. The anatomical location and repeated abscess formation likely contributed. While surgical removal of retained gallstones could have reduced the risk of fistula formation once identified, the decision must be balanced against operative risks, particularly in patients with mild or nonspecific symptoms. Case report session is well written. Authors summarize the long progression in compact. I would like to know at one year after procedure how do authors indicate treatment options to patients and his family. Authors described a CT just showed swelling around calcification. However the patient was conscious of abdominal tenderness, and the cause of tenderness is assumed to be lost gallstone. I think operation must be considered as the best treatment at this point. Authors should discuss more about this point. During the period between 15 and 18 months following the LC, subcutaneous abscesses were formed. The patient was treated with ultrasound-guided incision and drainage. Did authors take bacterial culture? How about antibacterial treatment? Proper antibacterial treatment is important for preventing for progression of diseases. If done, authors should mention detail antibacterial treatment such as choices, doses, duration etc. Response: Thank you for this thoughtful comment. Unfortunately, detailed information regarding discussions of treatment options with the patient and family is not available. Likewise, no additional data regarding bacterial cultures or antibiotic therapy were available. We agree that microbiological evaluation and appropriate antibiotic treatment are important considerations in such cases, and we acknowledge this as a limitation of the present report. The discussion session is also well written. However authors did not mentioned fistula with communication to pleura. I would like to know why the patient developed fistula. What is the main factor of fistulization? The position of spilled gallstone? Inadequate treatment for abscess? Just after LC, did authors take CT? Of course operation for removing spilled gallstone might be best choice for preventing fistulization when the gallstone was found. Is there any other choice avoiding fistula with communication to pleura? Authors should discuss about this point Response: Thank you for this comment. The exact mechanism of the fistulation remains unclear, but it might have been driven by chronic inflammation originating from the retained gallstones. The anatomical location and repeated abscess formation likely contributed. While surgical removal of retained gallstones could have reduced the risk of fistula formation once identified, the decision must be balanced against operative risks, particularly in patients with mild or nonspecific symptoms. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 21 Jan 2026 Jeanett Klubien , Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev, Denmark 21 Jan 2026 Author Response Case report session is well written. Authors summarize the long progression in compact. I would like to know at one year after procedure how do authors indicate treatment ... Continue reading Case report session is well written. Authors summarize the long progression in compact. I would like to know at one year after procedure how do authors indicate treatment options to patients and his family. Authors described a CT just showed swelling around calcification. However the patient was conscious of abdominal tenderness, and the cause of tenderness is assumed to be lost gallstone. I think operation must be considered as the best treatment at this point. Authors should discuss more about this point. During the period between 15 and 18 months following the LC, subcutaneous abscesses were formed. The patient was treated with ultrasound-guided incision and drainage. Did authors take bacterial culture? How about antibacterial treatment? Proper antibacterial treatment is important for preventing for progression of diseases. If done, authors should mention detail antibacterial treatment such as choices, doses, duration etc. Response: Thank you for this thoughtful comment. Unfortunately, detailed information regarding discussions of treatment options with the patient and family is not available. Likewise, no additional data regarding bacterial cultures or antibiotic therapy were available. We agree that microbiological evaluation and appropriate antibiotic treatment are important considerations in such cases, and we acknowledge this as a limitation of the present report. The discussion session is also well written. However authors did not mentioned fistula with communication to pleura. I would like to know why the patient developed fistula. What is the main factor of fistulization? The position of spilled gallstone? Inadequate treatment for abscess? Just after LC, did authors take CT? Of course operation for removing spilled gallstone might be best choice for preventing fistulization when the gallstone was found. Is there any other choice avoiding fistula with communication to pleura? Authors should discuss about this point Response: Thank you for this comment. The exact mechanism of the fistulation remains unclear, but it might have been driven by chronic inflammation originating from the retained gallstones. The anatomical location and repeated abscess formation likely contributed. While surgical removal of retained gallstones could have reduced the risk of fistula formation once identified, the decision must be balanced against operative risks, particularly in patients with mild or nonspecific symptoms. Case report session is well written. Authors summarize the long progression in compact. I would like to know at one year after procedure how do authors indicate treatment options to patients and his family. Authors described a CT just showed swelling around calcification. However the patient was conscious of abdominal tenderness, and the cause of tenderness is assumed to be lost gallstone. I think operation must be considered as the best treatment at this point. Authors should discuss more about this point. During the period between 15 and 18 months following the LC, subcutaneous abscesses were formed. The patient was treated with ultrasound-guided incision and drainage. Did authors take bacterial culture? How about antibacterial treatment? Proper antibacterial treatment is important for preventing for progression of diseases. If done, authors should mention detail antibacterial treatment such as choices, doses, duration etc. Response: Thank you for this thoughtful comment. Unfortunately, detailed information regarding discussions of treatment options with the patient and family is not available. Likewise, no additional data regarding bacterial cultures or antibiotic therapy were available. We agree that microbiological evaluation and appropriate antibiotic treatment are important considerations in such cases, and we acknowledge this as a limitation of the present report. The discussion session is also well written. However authors did not mentioned fistula with communication to pleura. I would like to know why the patient developed fistula. What is the main factor of fistulization? The position of spilled gallstone? Inadequate treatment for abscess? Just after LC, did authors take CT? Of course operation for removing spilled gallstone might be best choice for preventing fistulization when the gallstone was found. Is there any other choice avoiding fistula with communication to pleura? Authors should discuss about this point Response: Thank you for this comment. The exact mechanism of the fistulation remains unclear, but it might have been driven by chronic inflammation originating from the retained gallstones. The anatomical location and repeated abscess formation likely contributed. While surgical removal of retained gallstones could have reduced the risk of fistula formation once identified, the decision must be balanced against operative risks, particularly in patients with mild or nonspecific symptoms. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Sandblom G. Reviewer Report For: Case Report: Multiple complications after laparoscopic cholecystectomy with perforation and spilled gallstones [version 2; peer review: 2 approved with reservations] . F1000Research 2026, 5 :2322 ( https://doi.org/10.5256/f1000research.10221.r16285 ) The direct URL for this report is: https://f1000research.com/articles/5-2322/v1#referee-response-16285 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 26 Sep 2016 Gabriel Sandblom , Department of Clinical Sciences, Intervention and Technology, Karolinska Institute, Stockholm, Sweden Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.10221.r16285 The report describes a rare case where spilled gallstones following laparoscopic cholecystectomy resulted in fistulas to the subcutaneous tissue as well as to the pleura. Albeit an uncommon late complication from spilled gallstones, the report is an important reminder of ... Continue reading READ ALL The report describes a rare case where spilled gallstones following laparoscopic cholecystectomy resulted in fistulas to the subcutaneous tissue as well as to the pleura. Albeit an uncommon late complication from spilled gallstones, the report is an important reminder of the hazards of gallstone surgery and an argument for careful surgical technique in laparoscopic cholecystectomy for acute cholecystitis. Even if there is no high risk of developing severe complications such as those described in the report, it should be kept in mind when performing laparoscopic cholecystectomy. Granulomas due to gallstones left in the abdominal cavity is probably an overseen complication following gallstone surgery that may cause persisting pain. Comments: Did the report from the cholecystectomy include more detailed description of the spilled gallstones? Where the gallstones left in the trochar site (which could explain the subcutaneous fistlulas)? Where any attempts taken to extract the stones? Were any bacterial cultures taken? The aggressive local growth, with formation of abscesses as well as fistulas raised the suspicion of uncommon pathogens (e.g. Salmonella Virchow or Clostridium perfringens) In the discussion “In this case, the gallstones were found on CT before complications developed. Perhaps, the abscesses and fistula could have been avoided if the stones had been removed when they were discovered.”. Do the authors suggest a repeated laparoscopic procedure, even in asymptomatic patients, in order to remove spilled gallstones? This seems like a slightly hyperbolic recommendation from this single experience. A laparoscopic exploration aimed at discovering gallstones overseen at the first procedure may hardly be expected to reduce the risk of late complications. Competing Interests: No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Sandblom G. Reviewer Report For: Case Report: Multiple complications after laparoscopic cholecystectomy with perforation and spilled gallstones [version 2; peer review: 2 approved with reservations] . F1000Research 2026, 5 :2322 ( https://doi.org/10.5256/f1000research.10221.r16285 ) The direct URL for this report is: https://f1000research.com/articles/5-2322/v1#referee-response-16285 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 21 Jan 2026 Jeanett Klubien , Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev, Denmark 21 Jan 2026 Author Response Did the report from the cholecystectomy include more detailed description of the spilled gallstones? Where the gallstones left in the trochar site (which could explain the subcutaneous fistlulas)? ... Continue reading Did the report from the cholecystectomy include more detailed description of the spilled gallstones? Where the gallstones left in the trochar site (which could explain the subcutaneous fistlulas)? Where any attempts taken to extract the stones? Response: Thank you for this comment. The operative report did not have a more detailed description than already presented in the manuscript. All visible gallstones were removed intraoperatively, and the peritoneal cavity was irrigated with saline to retrieve any additional gallstones; no stones were left intentionally. Were any bacterial cultures taken? The aggressive local growth, with formation of abscesses as well as fistulas raised the suspicion of uncommon pathogens (e.g. Salmonella Virchow or Clostridium perfringens) Response: Thank you for this insightful comment. Unfortunately, information regarding bacterial cultures, including identification of specific pathogens, was not available. In the discussion “In this case, the gallstones were found on CT before complications developed. Perhaps, the abscesses and fistula could have been avoided if the stones had been removed when they were discovered.”. Do the authors suggest a repeated laparoscopic procedure, even in asymptomatic patients, in order to remove spilled gallstones? This seems like a slightly hyperbolic recommendation from this single experience. A laparoscopic exploration aimed at discovering gallstones overseen at the first procedure may hardly be expected to reduce the risk of late complications. Response: We appreciate the comment and fully agree that a recommendation should not be based on a single case. We do not advocate for repeated laparoscopic exploration in asymptomatic patients to retrieve lost gallstones. We intended to reflect on this specific case, where calcifications presumed to be gallstones were identified on CT imaging. At that time, the patient’s symptoms were mild, and the potential risks of surgical intervention were considered to outweigh the possible benefits. Did the report from the cholecystectomy include more detailed description of the spilled gallstones? Where the gallstones left in the trochar site (which could explain the subcutaneous fistlulas)? Where any attempts taken to extract the stones? Response: Thank you for this comment. The operative report did not have a more detailed description than already presented in the manuscript. All visible gallstones were removed intraoperatively, and the peritoneal cavity was irrigated with saline to retrieve any additional gallstones; no stones were left intentionally. Were any bacterial cultures taken? The aggressive local growth, with formation of abscesses as well as fistulas raised the suspicion of uncommon pathogens (e.g. Salmonella Virchow or Clostridium perfringens) Response: Thank you for this insightful comment. Unfortunately, information regarding bacterial cultures, including identification of specific pathogens, was not available. In the discussion “In this case, the gallstones were found on CT before complications developed. Perhaps, the abscesses and fistula could have been avoided if the stones had been removed when they were discovered.”. Do the authors suggest a repeated laparoscopic procedure, even in asymptomatic patients, in order to remove spilled gallstones? This seems like a slightly hyperbolic recommendation from this single experience. A laparoscopic exploration aimed at discovering gallstones overseen at the first procedure may hardly be expected to reduce the risk of late complications. Response: We appreciate the comment and fully agree that a recommendation should not be based on a single case. We do not advocate for repeated laparoscopic exploration in asymptomatic patients to retrieve lost gallstones. We intended to reflect on this specific case, where calcifications presumed to be gallstones were identified on CT imaging. At that time, the patient’s symptoms were mild, and the potential risks of surgical intervention were considered to outweigh the possible benefits. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 21 Jan 2026 Jeanett Klubien , Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev, Denmark 21 Jan 2026 Author Response Did the report from the cholecystectomy include more detailed description of the spilled gallstones? Where the gallstones left in the trochar site (which could explain the subcutaneous fistlulas)? ... Continue reading Did the report from the cholecystectomy include more detailed description of the spilled gallstones? Where the gallstones left in the trochar site (which could explain the subcutaneous fistlulas)? Where any attempts taken to extract the stones? Response: Thank you for this comment. The operative report did not have a more detailed description than already presented in the manuscript. All visible gallstones were removed intraoperatively, and the peritoneal cavity was irrigated with saline to retrieve any additional gallstones; no stones were left intentionally. Were any bacterial cultures taken? The aggressive local growth, with formation of abscesses as well as fistulas raised the suspicion of uncommon pathogens (e.g. Salmonella Virchow or Clostridium perfringens) Response: Thank you for this insightful comment. Unfortunately, information regarding bacterial cultures, including identification of specific pathogens, was not available. In the discussion “In this case, the gallstones were found on CT before complications developed. Perhaps, the abscesses and fistula could have been avoided if the stones had been removed when they were discovered.”. Do the authors suggest a repeated laparoscopic procedure, even in asymptomatic patients, in order to remove spilled gallstones? This seems like a slightly hyperbolic recommendation from this single experience. A laparoscopic exploration aimed at discovering gallstones overseen at the first procedure may hardly be expected to reduce the risk of late complications. Response: We appreciate the comment and fully agree that a recommendation should not be based on a single case. We do not advocate for repeated laparoscopic exploration in asymptomatic patients to retrieve lost gallstones. We intended to reflect on this specific case, where calcifications presumed to be gallstones were identified on CT imaging. At that time, the patient’s symptoms were mild, and the potential risks of surgical intervention were considered to outweigh the possible benefits. Did the report from the cholecystectomy include more detailed description of the spilled gallstones? Where the gallstones left in the trochar site (which could explain the subcutaneous fistlulas)? Where any attempts taken to extract the stones? Response: Thank you for this comment. The operative report did not have a more detailed description than already presented in the manuscript. All visible gallstones were removed intraoperatively, and the peritoneal cavity was irrigated with saline to retrieve any additional gallstones; no stones were left intentionally. Were any bacterial cultures taken? The aggressive local growth, with formation of abscesses as well as fistulas raised the suspicion of uncommon pathogens (e.g. Salmonella Virchow or Clostridium perfringens) Response: Thank you for this insightful comment. Unfortunately, information regarding bacterial cultures, including identification of specific pathogens, was not available. In the discussion “In this case, the gallstones were found on CT before complications developed. Perhaps, the abscesses and fistula could have been avoided if the stones had been removed when they were discovered.”. Do the authors suggest a repeated laparoscopic procedure, even in asymptomatic patients, in order to remove spilled gallstones? This seems like a slightly hyperbolic recommendation from this single experience. A laparoscopic exploration aimed at discovering gallstones overseen at the first procedure may hardly be expected to reduce the risk of late complications. Response: We appreciate the comment and fully agree that a recommendation should not be based on a single case. We do not advocate for repeated laparoscopic exploration in asymptomatic patients to retrieve lost gallstones. We intended to reflect on this specific case, where calcifications presumed to be gallstones were identified on CT imaging. At that time, the patient’s symptoms were mild, and the potential risks of surgical intervention were considered to outweigh the possible benefits. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 14 Sep 2016 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 13 May 26 Version 1 14 Sep 16 read read Gabriel Sandblom , Karolinska Institute, Stockholm, Sweden Tatsuhiro Masaoka , Keio University School of Medicine, Tokyo, Japan Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2016 Masaoka T. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 10 Oct 2016 | for Version 1 Tatsuhiro Masaoka , Department of Internal Medicine, Keio University School of Medicine, Tokyo, 160-8582, Japan 0 Views copyright © 2016 Masaoka T. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Authors reported a case complicated with stone spillage after laparoscopic cholecystectomy (LC). Perforation of the gallbladder during LC is a common complication and the incidence of lost stones during LC is not so rare. However it is rare that lost stones lead such a severe postoperative complication. So I think this paper is very interesting. However the authors had better concern the following points. Case report session is well written. Authors summarize the long progression in compact. I would like to know at one year after procedure how do authors indicate treatment options to patients and his family. Authors described a CT just showed swelling around calcification. However the patient was conscious of abdominal tenderness, and the cause of tenderness is assumed to be lost gallstone. I think operation must be considered as the best treatment at this point. Authors should discuss more about this point. During the period between 15 and 18 months following the LC, subcutaneous abscesses were formed. The patient was treated with ultrasound-guided incision and drainage. Did authors take bacterial culture? How about antibacterial treatment? Proper antibacterial treatment is important for preventing for progression of diseases. If done, authors should mention detail antibacterial treatment such as choices, doses, duration etc. The discussion session is also well written. However authors did not mentioned fistula with communication to pleura. I would like to know why the patient developed fistula. What is the main factor of fistulization? The position of spilled gallstone? Inadequate treatment for abscess? Just after LC, did authors take CT? Of course operation for removing spilled gallstone might be best choice for preventing fistulization when the gallstone was found. Is there any other choice avoiding fistula with communication to pleura? Authors should discuss about this point. Competing Interests No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 21 Jan 2026 Jeanett Klubien, Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev, Denmark Case report session is well written. Authors summarize the long progression in compact. I would like to know at one year after procedure how do authors indicate treatment options to patients and his family. Authors described a CT just showed swelling around calcification. However the patient was conscious of abdominal tenderness, and the cause of tenderness is assumed to be lost gallstone. I think operation must be considered as the best treatment at this point. Authors should discuss more about this point. During the period between 15 and 18 months following the LC, subcutaneous abscesses were formed. The patient was treated with ultrasound-guided incision and drainage. Did authors take bacterial culture? How about antibacterial treatment? Proper antibacterial treatment is important for preventing for progression of diseases. If done, authors should mention detail antibacterial treatment such as choices, doses, duration etc. Response: Thank you for this thoughtful comment. Unfortunately, detailed information regarding discussions of treatment options with the patient and family is not available. Likewise, no additional data regarding bacterial cultures or antibiotic therapy were available. We agree that microbiological evaluation and appropriate antibiotic treatment are important considerations in such cases, and we acknowledge this as a limitation of the present report. The discussion session is also well written. However authors did not mentioned fistula with communication to pleura. I would like to know why the patient developed fistula. What is the main factor of fistulization? The position of spilled gallstone? Inadequate treatment for abscess? Just after LC, did authors take CT? Of course operation for removing spilled gallstone might be best choice for preventing fistulization when the gallstone was found. Is there any other choice avoiding fistula with communication to pleura? Authors should discuss about this point Response: Thank you for this comment. The exact mechanism of the fistulation remains unclear, but it might have been driven by chronic inflammation originating from the retained gallstones. The anatomical location and repeated abscess formation likely contributed. While surgical removal of retained gallstones could have reduced the risk of fistula formation once identified, the decision must be balanced against operative risks, particularly in patients with mild or nonspecific symptoms. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Masaoka T. Peer Review Report For: Case Report: Multiple complications after laparoscopic cholecystectomy with perforation and spilled gallstones [version 2; peer review: 2 approved with reservations] . F1000Research 2026, 5 :2322 ( https://doi.org/10.5256/f1000research.10221.r16707) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/5-2322/v1#referee-response-16707 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2016 Sandblom G. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 26 Sep 2016 | for Version 1 Gabriel Sandblom , Department of Clinical Sciences, Intervention and Technology, Karolinska Institute, Stockholm, Sweden 0 Views copyright © 2016 Sandblom G. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The report describes a rare case where spilled gallstones following laparoscopic cholecystectomy resulted in fistulas to the subcutaneous tissue as well as to the pleura. Albeit an uncommon late complication from spilled gallstones, the report is an important reminder of the hazards of gallstone surgery and an argument for careful surgical technique in laparoscopic cholecystectomy for acute cholecystitis. Even if there is no high risk of developing severe complications such as those described in the report, it should be kept in mind when performing laparoscopic cholecystectomy. Granulomas due to gallstones left in the abdominal cavity is probably an overseen complication following gallstone surgery that may cause persisting pain. Comments: Did the report from the cholecystectomy include more detailed description of the spilled gallstones? Where the gallstones left in the trochar site (which could explain the subcutaneous fistlulas)? Where any attempts taken to extract the stones? Were any bacterial cultures taken? The aggressive local growth, with formation of abscesses as well as fistulas raised the suspicion of uncommon pathogens (e.g. Salmonella Virchow or Clostridium perfringens) In the discussion “In this case, the gallstones were found on CT before complications developed. Perhaps, the abscesses and fistula could have been avoided if the stones had been removed when they were discovered.”. Do the authors suggest a repeated laparoscopic procedure, even in asymptomatic patients, in order to remove spilled gallstones? This seems like a slightly hyperbolic recommendation from this single experience. A laparoscopic exploration aimed at discovering gallstones overseen at the first procedure may hardly be expected to reduce the risk of late complications. Competing Interests No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 21 Jan 2026 Jeanett Klubien, Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev, Denmark Did the report from the cholecystectomy include more detailed description of the spilled gallstones? Where the gallstones left in the trochar site (which could explain the subcutaneous fistlulas)? Where any attempts taken to extract the stones? Response: Thank you for this comment. The operative report did not have a more detailed description than already presented in the manuscript. All visible gallstones were removed intraoperatively, and the peritoneal cavity was irrigated with saline to retrieve any additional gallstones; no stones were left intentionally. Were any bacterial cultures taken? The aggressive local growth, with formation of abscesses as well as fistulas raised the suspicion of uncommon pathogens (e.g. Salmonella Virchow or Clostridium perfringens) Response: Thank you for this insightful comment. Unfortunately, information regarding bacterial cultures, including identification of specific pathogens, was not available. In the discussion “In this case, the gallstones were found on CT before complications developed. Perhaps, the abscesses and fistula could have been avoided if the stones had been removed when they were discovered.”. Do the authors suggest a repeated laparoscopic procedure, even in asymptomatic patients, in order to remove spilled gallstones? This seems like a slightly hyperbolic recommendation from this single experience. A laparoscopic exploration aimed at discovering gallstones overseen at the first procedure may hardly be expected to reduce the risk of late complications. Response: We appreciate the comment and fully agree that a recommendation should not be based on a single case. We do not advocate for repeated laparoscopic exploration in asymptomatic patients to retrieve lost gallstones. We intended to reflect on this specific case, where calcifications presumed to be gallstones were identified on CT imaging. At that time, the patient’s symptoms were mild, and the potential risks of surgical intervention were considered to outweigh the possible benefits. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Sandblom G. Peer Review Report For: Case Report: Multiple complications after laparoscopic cholecystectomy with perforation and spilled gallstones [version 2; peer review: 2 approved with reservations] . F1000Research 2026, 5 :2322 ( https://doi.org/10.5256/f1000research.10221.r16285) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/5-2322/v1#referee-response-16285 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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