What is the recommended treatment for a 19mm x 13mm gallstone (gall bladder calculi) impacted in the neck of the gallbladder?

Treatment of Impacted Gallstone in Gallbladder Neck

Laparoscopic cholecystectomy is the definitive treatment for a 19mm x 13mm gallstone impacted in the gallbladder neck, and should be performed promptly to prevent complications. 1, 2, 3

Why Surgery is Mandatory

This stone requires surgical removal—non-surgical options are not appropriate for stones of this size or location. The impacted position in the gallbladder neck creates high risk for acute cholecystitis, Mirizzi syndrome, and gallbladder perforation if left untreated. 1, 2

Non-Surgical Therapies Are Contraindicated

• Oral bile acid therapy (ursodeoxycholic acid) is limited to stones less than 15mm diameter and requires cholesterol-rich composition—your 19mm stone exceeds this threshold 4, 1, 5
• Extracorporeal shock-wave lithotripsy is effective only for stones smaller than 20mm, and is contraindicated for impacted stones in the neck 3, 5
• Contact dissolution with methyl-tert-butyl-ether remains investigational and is inappropriate for impacted stones 4, 3
• All non-surgical therapies fail to prevent gallstone recurrence (50% recurrence rate) or gallbladder cancer 4, 5

Surgical Approach

Laparoscopic cholecystectomy should be performed using the Critical View of Safety technique to minimize bile duct injury risk, which ranges from 0.4-1.5% 1, 2

Key Technical Considerations

• The impacted stone in the neck increases surgical difficulty and may require conversion to open surgery if visualization is inadequate 2
• Surgeon experience is critical—ensure your surgeon has substantial laparoscopic experience, particularly with complicated cases 4, 1, 2
• A "fundus-first" approach may be necessary if the impacted stone prevents safe dissection of Calot's triangle 2
• Success rates for laparoscopic cholecystectomy exceed 97% even in complicated cases 1, 2

Timing of Surgery

Perform surgery promptly rather than delaying, as the impacted position significantly increases complication risk:

• Impacted neck stones can cause acute cholecystitis, requiring emergency surgery with higher morbidity 1, 3
• Delayed intervention may occur when the patient is older and frailer, with substantially higher mortality 4
• Early laparoscopic cholecystectomy (within 7-10 days if symptoms develop) reduces complications 3

Pre-Operative Evaluation

Before surgery, assess for:

• Common bile duct stones using MRCP or endoscopic ultrasound, especially if there is any elevation in liver enzymes or bilirubin 1, 3
• Signs of acute cholecystitis (fever, leukocytosis, Murphy's sign) that would necessitate urgent rather than elective surgery 3
• Patient comorbidities that affect surgical risk, though even high-risk patients benefit from cholecystectomy over conservative management 3, 6

Common Pitfalls to Avoid

• Do not attempt watchful waiting—impacted stones are not candidates for expectant management due to high complication risk 1, 2
• Do not waste time with non-surgical therapies—the stone size and impacted position make these ineffective and delay definitive treatment 1, 2
• Do not underestimate the technical difficulty—impacted neck stones require experienced surgeons and may need conversion to open surgery 2
• Do not forget to evaluate the common bile duct—impacted neck stones can cause Mirizzi syndrome with CBD compression 1

Expected Outcomes

• Surgical mortality for women under 49 years is 0.054%, increasing with age and comorbidities 3
• Men have approximately twice the surgical mortality rate of women 1, 3
• Recovery time with laparoscopic approach is typically 1-2 weeks versus several months for open surgery 4, 3
• Surgery permanently eliminates risk of gallstone recurrence and gallbladder cancer 4, 1