G.L., a 42-year-old obese Caucasian woman, entered the hospital with nausea and vomiting, flatulence and eructation, a fever of 100.5°F, and continuous right upper quadrant and subscapular pain. Examination on admission showed rebound tenderness in the RUQ with a positive Murphy sign. Her skin, nails, and conjunctivae were yellowish, and she complained of frequent clay-colored stools. Her leukocyte count was 16,000. An ERCP and ultrasound of the abdomen suggested many small stones in her gallbladder and possibly the common bile duct. Her diagnosis was cholecystitis with cholelithiasis.

A laparoscopic cholecystectomy was attempted, with an intraoperative cholangiogram and common bile duct exploration. Because of G.L.'s size and some unexpected bleeding, visualization was difficult and the procedure was converted to an open approach. Small stones and granular sludge were irrigated from her common duct, and the gallbladder was removed. She had a T-tube inserted into the duct for bile drainage; this tube was removed on the second postoperative day. She had an NG tube in place before and during the surgery, which was also removed on day two. She was discharged on the fifth post-operative day with a prescription for prn pain medication and a low-fat diet.

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