What is the most appropriate management for a patient with severe abdominal pain, distension, and ascites 5 days after laparoscopic cholecystectomy?

Management of Post-Laparoscopic Cholecystectomy Complications with Ascites

Exploratory laparotomy is the most appropriate management for this patient presenting with severe abdominal pain, distension, and ascites 5 days after laparoscopic cholecystectomy, as these findings strongly suggest a serious surgical complication requiring immediate source control.

Immediate Diagnostic Considerations

This clinical presentation demands urgent evaluation for life-threatening complications:

• Bile duct injury or bile leak is the most critical concern, as cystic duct leakage or bile duct injury can present with ascites, abdominal pain, and peritonitis within the first postoperative week 1
• Gallbladder perforation (if missed intraoperatively) carries mortality rates of 12-16% and requires prompt surgical intervention 2
• Secondary peritonitis from any visceral injury must be excluded, as it requires both antibiotics with anaerobic coverage and laparotomy 2
• The vital signs showing borderline hypertension (BP 155) and low-grade fever (37.9°C) with severe symptoms indicate evolving sepsis 2

Why Exploratory Laparotomy is Indicated

The presence of severe abdominal pain, distension, and tenderness 5 days postoperatively represents a surgical emergency requiring definitive source control:

• Early diagnosis and immediate surgical intervention substantially decrease morbidity and mortality in cases of gallbladder perforation or bile duct injury 2
• Patients with suspected secondary peritonitis should receive anaerobic coverage plus third-generation cephalosporin and undergo laparotomy 2
• The timing (5 days post-op) and severity of symptoms make conservative management inappropriate 2
• Adequate source control is the cornerstone of managing intra-abdominal infections, and in this critically ill presentation, surgical exploration is mandatory 2

Why Other Options Are Inadequate

Percutaneous Drainage (Option B)

• Percutaneous drainage alone is insufficient when there is a surgical source requiring control (bile duct injury, perforation, or secondary peritonitis) 2
• While useful for localized collections or abscesses, it does not address the underlying surgical pathology in this acute presentation 2
• The patient's severe symptoms and tender abdomen indicate diffuse peritonitis, not a localized collection amenable to drainage 2

Diagnostic Laparoscopy (Option D)

• While diagnostic laparoscopy could identify the problem, conversion to open surgery is recommended in cases of severe local inflammation, adhesions, or suspected bile duct injury 2
• Given the 5-day interval with severe peritonitis, laparoscopic visualization will likely be compromised by inflammation and adhesions 2
• In the setting of hemodynamic instability and diffuse intra-abdominal infection, damage control procedures should be considered, which typically require open approach 2

Critical Pitfalls to Avoid

Do not delay surgical exploration while pursuing imaging or conservative measures:

• The clinical presentation alone (severe pain, distension, tender abdomen, ascites post-cholecystectomy) is sufficient to warrant immediate surgical intervention 2
• Delayed diagnosis of bile duct injury or perforation significantly increases morbidity and mortality 2
• If the setting, symptoms, or response are atypical, repeat paracentesis can help raise suspicion of secondary peritonitis and prompt surgical intervention 2
• However, in this case with clear peritoneal signs, diagnostic paracentesis should not delay definitive surgery 2

Preoperative Management

While preparing for surgery:

• Start broad-spectrum antibiotics immediately: third-generation cephalosporin (cefotaxime 2g IV q8h) plus anaerobic coverage for suspected secondary peritonitis 2
• Resuscitate with IV fluids and correct any electrolyte abnormalities 2
• In critically ill patients with intra-abdominal infections, multidisciplinary management including antibiotic stewardship is essential 2

Intraoperative Findings to Anticipate

During exploratory laparotomy, look for:

• Bile duct injury or cystic duct stump leak - the most common serious complication requiring repair and drainage 1
• Gallbladder perforation or missed stones causing peritonitis 2
• Other visceral injuries (bowel perforation, vascular injury) 2
• The surgical strategy should focus on eliminating gross contamination and solving the source of infection 2

The answer is C: exploratory laparotomy 2