Stubborn stones: breakages of a mechanical lithotripter by an exceptionally hard gallstone.

To cite: Allen N, Pettit S, Ali A. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014204940 DESCRIPTION Endoscopic retrograde cholangiopancreatography (ERCP) is the predominate method of removing common bile duct (CBD) calculi. The simplest and quickest way of removing large CBD calculi during ERCP is a mechanical lithotripter to crush the gallstone before removing the crushed fragments using balloon sweeping or a dormia extraction basket. We describe a case where the handle of the mechanical lithotripter broke off the metal sheath during crushing of an exceptionally hard 2 cm gallstone in an 83-year-old patient. This left the wire basket of the lithotripter firmly impacted around the gallstone in the CBD with the sheath of the lithotripter protruding from the patient’s mouth (figure 1). Attempts to remove the lithotripter failed. The patient was transferred to the operating theatre and under general anaesthetic an upper midline laparotomy incision was made. The CBD was opened longitudinally allowing the impacted lithotripter basket and gallstone to be extracted (figure 2). The metal wires and sheath were divided near the entrapped basket (figure 3) using a wire cutter, allowing the sheath to be withdrawn from the patient’s mouth. The CBD was closed using a continuous suture and cholecystectomy was performed. The patient was discharged 7 days later. Mechanical lithotriptors are designed so that the crushing wire basket preferentially breaks rather