AB243. SOH26AB_0263. Beyond the scalpel: When a routine case becomes a diagnostic puzzle—a case report

Background: Retained common bile duct (CBD) stones are an important postoperative complication of laparoscopic cholecystectomy, occurring in 2–5% of cases and frequently leading to readmission. Identifying silent or asymptomatic CBD stones pre- or intraoperatively remains challenging. This case illustrates the diagnostic difficulty and clinical consequences of retained stones, and highlights current evidence regarding the role of routine versus selective intraoperative cholangiography (IOC).

Case Description: A 37-year-old woman underwent an elective laparoscopic cholecystectomy for symptomatic gallstones. Her postoperative course was reviewed alongside sequential investigations, including computed tomography (CT), ultrasound, magnetic resonance cholangiopancreatography (MRCP), and two endoscopic retrograde cholangiopancreatography (ERCP) attempts. The case was contextualised with findings from observational studies, meta-analyses, and current guidelines evaluating risk factors for retained stones and the effectiveness of IOC in their detection and prevention. The patient re-presented twice with severe upper abdominal and right-upper-quadrant pain. Early imaging suggested a postoperative collection without interval change. Progressive symptoms led to deranged liver function tests and MRCP evidence of an abrupt CBD cut-off with suspected distal stones. The first ERCP failed due to difficult cannulation; a repeat procedure subsequently retrieved a single CBD stone, with clinical resolution and discharge. Literature review shows cystic duct stones and subtotal cholecystectomy as strong independent risk factors for retained stones, and demonstrates that routine IOC detects over three times more CBD stones than selective IOC, with potential reductions in retained stones and bile duct injury.

Conclusions: This case underscores how retained CBD stones can remain occult despite early imaging and stable postoperative observations. Routine IOC may prevent similar delayed presentations by improving stone detection and reducing postoperative morbidity. When retained stones occur, ERCP and laparoscopic CBD exploration remain complementary tools, with management best tailored to anatomy, expertise, and institutional resources. The optimal strategy combines prevention through routine IOC with minimally invasive, timely intervention.

Keywords: Retained common bile duct stones (retained CBD stones); intraoperative cholangiography (IOC); laparoscopic cholecystectomy; postoperative complications; case report