This study presents two cases where percutaneous nephrolithotomy (PCNL) principles and holmium laser lithotripsy were adapted to treat cholelithiasis (gallstones) in patients unsuitable for traditional open or laparoscopic surgery. The first case involved a 63-year-old woman with chronic cholecystitis complicated by an enterocutaneous fistula, requiring long-term biliary drainage. She was admitted with septic shock caused by a 2.5 cm obstructing gallstone. The second case involved an 83-year-old woman with high cardiac risk and gangrenous cholecystitis who had a poorly tolerated cholecystostomy tube. After a multidisciplinary team discussion, percutaneous stone removal was deemed the best approach.
Both patients had pre-existing cholecystostomy tubes inserted through hepatic tissue. The procedure involved placing a guidewire, dilating with renal dilators up to 18 French, and advancing an 18 French ClearPetra™ sheath into the biliary system under fluoroscopic guidance. Holmium laser lithotripsy was then used in fragmenting and dusting modes. In the first case, the single 2.5 cm gallstone was successfully fragmented and evacuated. The second case involved numerous stones, requiring two sessions for complete removal. A 12 French percutaneous pigtail catheter was placed post-procedure to ensure proper drainage. The first patient had no complications and was discharged on postoperative day 7. For both cases, the mini-PCNL setup proved effective, using smaller dilators and sheath, eliminating the need for a larger offset nephroscope.
These cases highlight the versatility of endourological techniques in managing gallstones in patients who are poor candidates for traditional surgery. This approach demonstrates a safe, effective alternative for complex cholelithiasis cases and merits further study as a non-invasive treatment for high-risk surgical patients.
