The Pucker sign: an operative and radiological indicator of impending operative difficulty due to severe chronic contractive inflammation in cholecystectomy

Introduction: Marked inflammatory contraction of the gallbladder at the time of cholecystectomy is associated with biliary injury. Methods: The evolution of contraction is traced in two patients who developed acute cholecystitis. Results: Within months the gallbladder became fibrotically contacted and in doing so pulled the adjacent liver down, puckering the surface of the liver. This puckering could be observed preoperatively on computed tomography and also visually at the time of surgery. Conclusions: Puckering of the liver (“Pucker sign”) can alert the surgeon to the presence of severe contractive inflammation.