Laparoscopic cholecystectomy: The missed diagnosis

Background: All 534 laparoscopic cholecystectomies performed by five surgeons at a single institution over a 3-year period were reviewed as part of a quality assurance process. The aim of the review, which has previously been published in this journal, was to identify and quantify complications of the procedure. Five cases in this series were recognized where major intra-abdominal pathology not identified at the time of laparoscopic cholecystectomy required laparotomy shortly thereafter. These five cases are reported here because there has been little discussion in the literature of this problem associated with laparoscopic cholecystectomy. Methods: The records of all 534 patients having a laparoscopic cholecystectomy between October 1990 and September 1993 were reviewed and entered into a computer database (Microsoft Access). This data collection and recording have subsequently become an ongoing process of quality assurance. Results: Five of 534 patients treated by laparoscopic cholecystectomy failed to have resolution of their symptoms postoperatively. A laparotomy was subsequently required within 3-12 months which demonstrated causative pathology present, but not detected at, the time of laparoscopic cholecystectomy. Where possible, treatment of these laparotomy findings resolved the initial presenting symptoms of colicky epigastric pain. Conclusions: The rate of 'missed diagnosis' is found to be < 1%. Laparoscopic cholecystectomy is a therapeutic, rather than diagnostic, procedure, and pre-operative discussion should include the possibility of further procedures being required subsequently, particularly when symptoms and signs are atypical.