Mini-Laparotomy Enterolithotomy for Gallstone Ileus in an Elderly Patient: A Case Report

Gallstone ileus is an uncommon cause of mechanical small-bowel obstruction resulting from migration of a gallstone through a biliary-enteric fistula and occurs predominantly in older adults. A 70-year-old man with treated hypertension and recurrent, conservatively managed cholecystitis presented with three days of abdominal pain, vomiting, and progressive distension. He was febrile (38°C), tachycardic (110 beats/min), and had a blood pressure of 100/60 mmHg. Laboratory testing showed mild acute kidney injury, mild hypokalemia and hypochloremia, and a moderate inflammatory response. After initial resuscitation, the anesthesiology team classified the patient as American Society of Anesthesiologists physical status IIE, with "E" denoting emergency surgery. Computed tomography demonstrated small-bowel obstruction, pneumobilia, and a 37-mm ectopic gallstone, with a suspected cholecystoduodenal fistula. At surgery, the stone was located approximately 30 cm proximal to the ileocecal valve. Through an open periumbilical mini-laparotomy extending above and below the umbilicus, the viable ileal loop was exteriorized without laparoscopic assistance. A longitudinal antimesenteric enterotomy allowed extraction of a 4-cm stone, followed by transverse closure in two layers without apparent luminal narrowing. No residual gallstones were detected by manual palpation of the gallbladder through the incision; the suspected fistula was not explored. Recovery was uncomplicated, and the patient was discharged on postoperative day four. At one month, the patient was clinically well, but he subsequently missed scheduled appointments and was lost to follow-up. This case illustrates short-term relief of obstruction after mini-laparotomy enterolithotomy alone; long-term biliary outcomes could not be assessed.