The sac of gall; trans‐parastomal hernia cholecystectomy for incarcerated, acalculous cholecystitis

A 90 year old man presented with 1 day of abdominal pain emanating from his parastomal hernia. His medical history included a cystectomy and ileal conduit performed in 1987 for bladder carcinoma. On examination he had a tender, irreducible parastomal hernia. Bloods showed WCC 11.4 and CRP 45, with normal LFTs. Admission CT showed herniation of the gallbladder into the right lateral abdominal wall hernia with surrounding free fluid and inflammatory change, but no radio-opaque gallstones. He improved with medical management and was discharged home. 11 days after index admission, he represented with recurrence of pain. Bloods showed WCC 12.8 CRP 2 and LFTs normal. Imaging again demonstrated acute acalculous cholecystitis with gallbladder herniation into the parastomal hernia. On this occasion he worsened despite antibiotics and developed new skin changes over the hernia. Repeat CT scan (Figs. 1 and 2) suggested gangrenous cholecystitis and possible ischaemia secondary to strangulation. In accordance with the patient's wishes, he proceeded for surgical management with open cholecystectomy. Intra-operative findings were gangrenous gallbladder with extensive adhesions to the parastomal hernia sac. Intraoperatively an upper para-midline incision was made, however, the gallbladder could not be delivered into the abdominal cavity safely due to dense adhesions. A second incision was then made over the upper aspect of the parastomal hernia, (Fig. 3) the gallbladder was carefully dissected away from the hernia sac and freed into the peritoneal cavity. A top-down cholecystectomy was performed. Decision was made against fixing the parastomal hernia due to dense bowel adhesions, degree of sepsis and comorbidity of the patient. Post-operatively he recovered well and was discharged to his usual place of residence on post-op day six. Histology confirmed acalculous gangrenous cholecystitis. Acalculous cholecystitis secondary to gallbladder incarceration within parastomal hernia is incredibly rare. A PUBMED search for 'cholecystitis', 'parastomal', 'hernia' returned eight articles. Of these, only two cases of acalculous cholecystitis secondary to gallbladder incarceration in parastomal hernia were identified. The other cases pertained to; incidental non-cholecystitis gallbladder herniation into parastomal hernia,1 calculous cholecystitis,2, 3 gallbladder volvulus4 and cholecystitis secondary to groove pancreatitis5 all within a parastomal hernia. Both cases of acalculous cholecystitis were managed with cholecystectomy. This is the first such case of recurrence following conservative management being managed operatively on re-presentation. Of the seven cases of cholecystitis in a parastomal hernia found in the literature, one was successfully managed non-operatively, one was found to have spontaneously reduced upon laparoscopy6 and subsequently managed medically, and the remaining five underwent successful cholecystectomy. The mean age of the seven cases was 76 years old. Five of the patients were female, two were male. Julia Shearer: Conceptualization; writing – review and editing. Jonathan Johns: Conceptualization; project administration; writing – original draft; writing – review and editing. Cain Anderson: Writing – original draft. Jacques Marnewick: Conceptualization; resources. Mark Omundsen: Conceptualization; supervision. The case, text and publication has been discussed with the patient involved and they have granted their whole-hearted permission for publication.