A 70-year-old woman presents with recurrent colicky abdominal pain, distension, and vomiting. Plain radiograph shows pneumobilia, a calcified shadow in the right iliac fossa, and dilated small bowel loops. What is the most appropriate surgical procedure?

• A Cholecystectomy with T-tube drainage of the common bile duct
• B Enterolithotomy with cholecystectomy and fistula repair in the same sitting
• C Right hemicolectomy
• D Enterolithotomy only ✓

Explanation

Rigler's triad of pneumobilia, small bowel obstruction, and an ectopic gallstone indicates gallstone ileus from a cholecystoduodenal fistula. In an elderly patient the standard approach is simple enterolithotomy to relieve the obstruction, deferring any fistula repair because single-stage cholecystectomy and fistula closure carry high morbidity in this group. Right hemicolectomy addresses malignancy, not an impacted stone, and T-tube drainage does not address the obstructing stone.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

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