gall bladder ( gb ) perforation is a rare visceral complication of percutaneous nephrolithotomy ( pnl ) that carries a high mortality . we report a case of biliary peritonitis due to gb perforation that occurred after an otherwise uneventful pnl . a 19-year - old male patient underwent pnl for a 1.5  1.5 cm right renal lower pole stone . stone - guided bull 's eye puncture with fluoroscopy unit in 0 degree and 30 degree was performed with an 18 gauge needle . after the c arm showed the needle near the desired calyx in 0 degree , it was rotated to 30 degree toward the surgeon and access to the calyx was sought by aligning the needle with it . this step required minor adjustments and resulted in multiple passes ( about six ) of the puncture needle . the stone was removed in toto without use of lithotripsy and a 26 fr nephrostomy tube ( pcn ) was applied . the patient recovered well after the operation and was asymptomatic for the next 2 days except for mild abdominal pain . his nephrostomy output was clear and was left in situ for 2 days according to the institutional protocol . on the evening of the second post - operative day , the patient developed abdominal distension and pain along with hemodynamic instability ( bp = 90/60 ) , tachycardia and decreased urine output . x - ray abdomen did not reveal any free air in the abdomen or air fluid levels . x - ray chest was normal and ultrasound ( usg ) abdomen revealed free fluid in the abdomen . an usg - guided pelvic drain was placed that extruded 1.5 l of golden yellow bilous aspirate . exploratory laparotomy was performed on the third post - operative day , about 56 h after the procedure . three small perforations were noted in the body of the gb on the posterior surface . a small perforation was noted in the caudate lobe of the liver . the whole gut was carefully examined along with mobilization of the right colon and kocherisation of the duodenum , but no other perforation was identified . isolated gb perforation is a rare complication of pnl with few cases reported in the literature . cases carry a high mortality due to delay in diagnosis and the irritant nature of the bile . described a case of gb perforation that was diagnosed 48 h after the procedure and treated with laparoscopic procedure and cholecystectomy . described two cases where , in the first case , the patient underwent exploratory laparotomy for biliary peritonitis with cholecystectomy and insertion of a t - tube into the bile duct 48 h after standard pnl . the patient underwent exploratory laparotomy and cholecystectomy 12 h after the procedure for biliary peritonitis . turner et al . have reported the only case in the literature where the diagnosis was made intraoperatively by opacification of the gb by a radiocontrast agent . described the first case of duodenal injury with biliary peritonitis caused by choledochal necrosis and bile leakage following pcnl . this is also the only case reported in the literature with a fatal outcome , with the cause designated as septic shock with acute respiratory distress syndrome . gb perforation should be kept in mind during right - sided pnl in lean and thin patients . the distance between calyces of the right kidney and the gb can be as little as 2 cm . a combination of fluoroscopy and ultrasound should be used for access . in our case , the patient was thin and the initial access was directly stone guided , which may have contributed to the injury . although the skin was punctured at a single point and the needle was placed at the desired calyx , thereafter the 18 g needle required adjustments with the c arm in 30 degree before free flow of urine was aspirated from the puncture needle . this step required multiple passes ( about six ) back and forth of the needle . looking at the size and number of the gb perforations , we assume that this is the step at which the injury occurred . surgeons tend to be more adventurous with a thin needle rather than with the thick dilators . we believe that even microscopic injuries to the gb are significant , and this has also been reported in the literature . credence to our theory comes from observations from cholecystectomy , where sometimes a tense gb needs to be aspirated before removal . absence of free air under the diaphragm also occurs in the absence of concomitant bowel injury . most cases in the literature have reported an average delay of 48 h to diagnosis , matching our own time period of 56 h. all cases reported in the literature have required open or laparoscopic cholecystectomy . urologists performing pnl must keep the possibility of biliary peritonitis in mind , especially when a thin patient develops unexplained peritonitis after a right - sided procedure . laparotomy or laparoscopy is the most definite way to diagnose this condition as there is an absence of early clinical signs . it must be remembered that the condition is a life - threatening complication if there is delay or failure to diagnose .
a 19-year - old male patient underwent right percutaneous nephrolithotomy ( pnl ) for right renal 1.5  1.5 cm lower pole stone . 
 the procedure was completed uneventfully with complete stone clearance . 
 the patient developed peritonitis and shock 48 h after the procedure . 
 exploratory laparotomy revealed a large amount of bile in the abdomen along with three small perforations in the gall bladder ( gb ) and one perforation in the caudate lobe of the liver . 
 retrograde cholecystectomy was performed but the patient did not recover and expired post - operatively . this case exemplifies the high mortality of gb perforation after pnl and the lack of early clinical signs .