Unexplained ascites following laparoscopic cholecystectomy: A surgeon's nightmare - A case report and review of literature.

Laparoscopic cholecystectomy has many known complications which can be ascertained to a particular cause. We report a case of ascites development in a young female immediately after Laparoscopic cholecystectomy, for which a cause cannot be found. On review of medical literature, there are few similar case reports, based on them; it can be ascertained to acute allergic reaction to the material used during the procedure may be the CO2 or the electrocautery.

INTRODUCTION

Minimising complications after surgical procedures is a cherished goal of every surgical specialist. Sometimes, there may be post-operative developments which are not only unexpected but also difficult to explain.

CASE REPORT

A 19-year-old female with no known allergy underwent three-port laparoscopic cholecystectomy for symptomatic cholelithiasis. The operation was uneventful with satisfactory haemostasis, no bile leakage or stone spillage. Six hours after surgery she tolerated oral diet well. Later, on she developed severe abdominal pain, nausea and bilious vomiting. She was afebrile, hemodynamically stable, with mild abdominal distention and mild diffuse tenderness. Routine blood investigations and serum amylase/lipase were normal. A plain X-ray of the abdomen showed insignificant air-fluid levels. Abdominal ultrasound revealed a large quantity of fluid within the abdominal cavity, more in the parahepatic and pelvic regions. A diagnostic tap revealed the fluid to be straw coloured with no foul smell. An intraperitoneal pigtail catheter placement was done under ultrasound guidance, and almost 1 L of clear ascitic fluid was drained, with which symptoms improved dramatically. Fluid analysis revealed glucose 124 mg/dl, protein 4.3 g/dl, negativity for bile salts and pigments, normal fluid amylase and lipase levels. Fluid culture did not reveal the growth of any pathogenic bacteria. A contrast-enhanced computed tomography abdomen done subsequently did not reveal any intra-abdominal pathology that could explain the cause of the ascites. A magnetic resonance cholangiopancreatography ruled out any biliary injury, and cystic duct clips were in situ. The fluid drainage on subsequent days was: 14 ml, 75 ml, 19 ml and 8 ml daily. The consistency and colour of fluid was the same throughout i.e., thin and straw coloured with mild blood staining. The patient was kept on supportive treatment and intravenous antibiotics. No antihistamines or steroids were given. Pigtail catheter was removed on post-operative day #7. In the follow-up period, she did not have any symptoms or further fluid accumulation.

DISCUSSION AND REVIEW OF LITERATURE

Our patient was an unusual case of post-operative ascites, which developed after uneventful laparoscopic cholecystectomy. The accumulation of intra-abdominal fluid after laparoscopic surgery immediately raises the suspicion towards specific complications as the cause. It may be bilious, enteric, blood, chyle and urine depending on the organ of injury. The patient may develop pancreatic or bacterial ascites in case of post-operative pancreatitis or infection. Nature of the fluid and imaging ruled out biliary and enteric injury in this case. Chylous ascites was ruled out as the fluid was clear (not milky) and no retroperitoneal dissection was done. Acute pancreatic ascites was ruled out as the amylase and lipase levels were normal. Bacterial ascites was ruled out as it usually leads to a turbid, foul smell collection with the symptom of fever. Furthermore, bacterial culture was negative. Extensive search done to look for similar cases in medical history revealed only a few cases of post-laparoscopy ascites of unknown origin.

Alberto et al. reported a case of post-laparoscopy ascites of unknown cause in a 31-year-old female and concluded that the ascites was probably a result of an allergic or an abnormal peritoneal reaction to the diathermy.[1] In another case reported by Feretis et al., they suggested that probably some substances used during laparoscopy (carbon dioxide, light/heat and diathermy) may have triggered an inflammatory response.[2] Jiang et al.[3] reported eight cases of post-operative ascites of unknown etiology following laparoscopic gynaecologic surgery and suggested that the most likely cause of the ascites may be a diffuse peritoneal injury induced by certain substances used during the operation. A similar conclusion was made by Zhao et al.[4] when they reported a case of idiopathic post-operative ascites following laparoscopic salpingectomy. In some previous studies, presumed inflammatory reaction to methylene blue was reported after a laparoscopic procedure and chromopertubation.[5]

CONCLUSION

Ascites of unknown origin is a very rare complication following laparoscopic procedures. With no other attributable cause for the ascites, it was concluded to be a result of an acute allergic or inflammatory response to material used during the procedure, may be the CO2 or the electrocautery. As was the experience of others, our patient also was relieved of symptoms with drainage of the fluid. It is a generally a self-limiting ascites which resolves without any significant sequelae.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.