Totally Laparoscopic Management of Gallstone Ileus— Technical Report and Review of the Literature Apollon Zygomalas, MD, MSc, Stavros Karamanakos, MD, PhD, and Ioannis Kehagias, MD, PhD Abstract Purpose: Gallstone ileus is an uncommon complication of gallstone disease. It occurs in elderly patients in up to 25% of the cases. The management of gallstone ileus remains controversial. Open surgery has been the mainstay of treatment, but laparoscopic surgery has recently been used. In this study we report a case of an 87-year-old female patient with gallstone ileus who has been managed totally laparoscopically, detailing the technique and discussing the advantages of the laparoscopic approach with a review of the literature. Methods: The pneumoperitoneum was established with a Veress needle. A three-port approach (one 5-mm and two 10-mm trocars) and a 30° 10-mm laparoscope were used. The site of obstruction was 5 cm below the ligament of Treitz, and a single gallstone was identified. A 3-cm longitudinal enterotomy was created just above the site where the gallstone was located. An 8-cm-long gallstone was extracted. The enterotomy was closed transversely in a single layer of two sets of continuous sutures. Results: The procedure was safely performed with all the advantages of minimally invasive surgery. Previous studies often described laparoscopically assisted procedures for the treatment of gallstone ileus, using a small abdominal incision. In recent years, some reports have been published on the efficacy of the totally laparoscopic approach in the management of gallstone ileus. Conclusions: Totally laparoscopic management of gallstone ileus could be safe and effective with suggested benefits for the elderly patients. Introduction G allstone ileus is an uncommon cause of small bowel obstruction, occurring when the formation of a fistula between the gallbladder and the bowel wall may allow one or more large gallstones to pass through the gallbladder and into the intestinal lumen. It is a rare complication of cholelithiasis, occurring in 0.3%–0.5% of all patients with gallstones. 1 The presentation is often nonspecific with intermittent symptoms, confounding diagnosis, and delaying treatment. 2,3 Gallstone ileus accounts for 1%–4% of all presentations to hospital with small bowel obstruction and for up to 25% of all cases in patients over 65 years of age. 4,5 Despite medical advances over recent years, gallstone ileus is still associated with high rates of morbidity and mortality. 3,6,7 The management of gallstone ileus remains controversial. Enterolithotomy alone rather than in combination with cho- lecystectomy is considered to be the procedure of choice for gallstone ileus, resulting in lower morbidity and mortality rates. 3,5,8 Open surgery has been the mainstay of treatment, but more recently laparoscopic surgery has been used. Thus far, only nine cases reported in the literature describe a totally laparoscopic approach. 9–15 In this study we report a case of a female patient with gallstone ileus who has been managed totally lapar- oscopically, detailing the technique and discussing the ad- vantages of the laparoscopic approach with a review of the literature. Materials and Methods Clinical summary A 87-year-old female patient with known cholelithiasis and episodes of acute cholecystitis in the past was admitted to our hospital with small bowel obstruction and presence of air in the gallbladder and the biliary tree. Her medical history in- cluded arterial hypertension and diabetes mellitus type 2 treated with insulin therapy. She did not have any prior ab- dominal operations. Department of General Surgery, University of Patras, School of Medicine, Rio, Patras, Greece. JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 22, Number 3, 2012 ª Mary Ann Liebert, Inc. DOI: 10.1089/lap.2011.0375 265