Stone retraction and incision at the level of Hartmann’s pouch during laparoscopic cholecystectomy in cases of stone impacted in the gallbladder neck: Comparative analysis of efficacy and safety

Aim. To compare outcomes of stone retraction and incision at the level of Hartmann’s pouch during laparoscopic cholecystectomy in patients with a stone impacted in the gallbladder neck.

Materials and methods. A retrospective single-center comparative study included 104 patients with calculous cholecystitis and an intraoperatively confirmed impacted stone in the gallbladder neck. Stone retraction without opening the gallbladder wall was performed in 62 patients, while 42 underwent incision of the gallbladder wall at the level of Hartmann’s pouch with stone extraction followed by continuation of cholecystectomy. Clinical, demographic, intraoperative characteristics and postoperative outcomes were analyzed, including complications graded according to the Clavien–Dindo classification.

Results. Baseline characteristics were comparable between groups. The overall complication rate was higher in the stone retraction group compared to the Hartmann’s pouch incision group (40.3 and 23.8 %, respectively; p = 0.044). Clinically significant complications (grade ≥IIIa per the Clavien–Dindo classification) occurred more frequently after stone retraction (22.6 % and 4.8 %, p = 0.014). No mortality was observed.

Conclusion. An impacted stone in the gallbladder neck may render standard dissection within the Calot’s triangle unsafe. Stone retraction is a reasonable initial step; however, early transition to incision at the level of the Hartmann’s pouch is advisable when it is ineffective. A stepwise algorithmic approach allows to decrease the rate of clinically significant complications and improve safety of the surgery.

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