Hepatobiliary anatomy in patients with transposition of the gallbladder: implications for safe laparoscopic cholecystectomy

Laparoscopic cholecystectomy for a gallbladder with a right sided round ligament using indocyanine green fluorescence imaging: A case report

INTRODUCTION

The gallbladder with a right sided round ligament is a rare anomaly. It is frequently associated with various biliary, vascular, and other anomalies. Herein, we present a case of a gallbladder with a right-sided round ligament treated with laparoscopic cholecystectomy using indocyanine green fluorescence imaging.

PRESENTATION OF CASE

A 50-year-old woman had right upper quadrant discomfort. Gallbladder stones, a polyp, and a right-sided round ligament were found on preoperative computed tomography. Laparoscopic cholecystectomy with indocyanine green fluorescence imaging was decided. During surgery, "fundus first technique" was performed and the biliary anatomy was confirmed with the aid of indocyanine green fluorescence guidance. The gallbladder was attached to segment 4 of the liver which was the left side of the round ligament. Cystic artery and cystic duct were ligated safely. The patient had no postoperative complication.

DISCUSSION

Although there are various anomalies in patients having a gallbladder with a rights-sided round ligament, ICG fluorescence imaging can show the anatomy of the extrahepatic biliary tree. It can enable surgeons to recognize concomitant vascular and biliary anomalies.

CONCLUSION

Laparoscopic cholecystectomy for gallbladder with a right-sided round ligament can be safely performed by identifying biliary anatomy with indocyanine green fluorescence imaging.

Laparoscopic cholecystectomy and common bile duct exploration for gallstone and common bile duct stone in a patient with a left-sided gallbladder: a case report

Left-sided gallbladder is a rare finding that is mostly discovered incidentally during surgery and is often associated with anatomic anomalies. We herein report a case in which laparoscopic cholecystectomy and common bile duct exploration were achieved for an 89-year-old female patient with left-sided gallbladder. Surgery was carried out using our usual trocar position. Calot triangle was covered by the body of the gallbladder and could not be detected. We dissected the gallbladder from the fundus towards the neck. The cystic duct joined the common bile duct from the right side, and common bile duct exploration was performed routinely without perioperative comorbidities. Although the preoperative diagnosis rate is low and the risk of intraoperative bile duct injuries in patients with left-sided gallbladder is high, laparoscopic cholecystectomy and common bile duct exploration can be safely performed by understanding the location and bifurcation of the cystic duct.

The Management and Challenges of Laparoscopic Cholecystectomy in Situs Inversus Abdominalis

Left-sided gallbladders are rare anatomical variations and a result of an abnormal embryological process. The most frequent cause for a sinistroposition gallbladder is the presence of situs inversus. We present a case of a 51-year-old male referred to the General Surgery consult due to cholelithiasis with a history of occasional post-prandial abdominal pain in the left hypochondrium and nausea associated with the ingestion of lipid-rich meals. The ultrasound revealed a gallbladder filled with calculous but without inflammatory signs or bile duct dilation, in the sinistroposition. Magnetic resonance imaging (MRI) confirmed and excluded further anatomic variations. The patient underwent a laparoscopic cholecystectomy due to symptomatic cholelithiasis without any complications and was discharged the following day. When faced with a patient with gallbladder/biliary duct disorders associated with situs inversus, one must have a high clinical index of suspicion to properly diagnose and the mental agility to adapt and further operate in a mirrored-positioned abdomen. In these situations the patient should always undergo a prior MRI to determine the correct anatomy of the biliary system and the surgeon should perform an intraoperative cholangiography if any other variations are suspected. The presence of situs inversus thus imposes a surgical and diagnostic challenge. Although rare the surgeon must be aware of this possibility.

Predicting portal venous anomalies by left-sided gallbladder or right-sided ligamentum teres hepatis: A large scale, propensity score-matched study

BACKGROUND

Right-sided ligamentum teres (RSLT) is often associated with portal venous anomalies (PVA) and is regarded as a concerning feature for hepatobiliary intervention. Most studies consider RSLT to be one of the causes of left-sided gallbladder (LGB), leading to the hypothesis that LGB must always be present with RSLT. However, some cases have shown that right-sided gallbladder (RGB) can also be present in livers with RSLT.

AIM

To highlight the rare variation that RSLT may not come with LGB and to determine whether ligamentum teres (LT) or gallbladder location is reliable to predict PVA.

METHODS

This study retrospectively assessed 8552 contrast-enhanced abdominal computed tomography examinations from 2018 to 2021 [4483 men, 4069 women; mean age, 59.5 ± 16.2 (SD) years]. We defined the surrogate outcome as major PVAs. The cases were divided into 4 subgroups according to gallbladder and LT locations. On one hand, we analyzed PVA prevalence by LT locations using gallbladder location as a controlled variable (n = 36). On the other hand, we controlled LT location and computed PVA prevalence by gallbladder locations (n = 34). Finally, we investigated LT location as an independent factor of PVA by using propensity score matching (PSM) and inverse probability of treatment weighting (IPTW).

RESULTS

We found 9 cases of RSLT present with RGB. Among the LGB cases, RSLT is associated with significantly higher PVA prevalence than typical LT [80.0% vs 18.2%, P = 0.001; OR = 18, 95% confidence interval (CI): 2.92-110.96]. When RSLT is present, we found no statistically significant difference in PVA prevalence for RGB and LGB cases (88.9 % vs 80.0%, P > 0.99). Both PSM and IPTW yielded balanced cohorts in demographics and gallbladder locations. The RSLT group had a significantly higher PVA prevalence after adjusted by PSM (77.3% vs 4.5%, P < 0.001; OR = 16.27, 95%CI: 2.25-117.53) and IPTW (82.5% vs 4.7%, P < 0.001).

CONCLUSION

RSLT doesn't consistently coexist with LGB. RSLT can predict PVA independently while the gallbladder location does not serve as a sufficient predictor.

Left-Sided Gall Bladder: An Anatomic Rarity and Its Implications

Left-sided gall bladder (LGB) is a rare anomaly seldom encountered by surgeons in clinical practice. Accurate preoperative diagnosis is rare due to the atypical localisation of pain in the right hypochondrial quadrant and the rarity of occurrence. This feature poses intraoperative challenges that mandate quick improvisation. Hence, all surgeons should gain knowledge of left-sided gall bladders, which can be associated with the risk of biliovascular injuries compared to normally positioned gall bladders. We present an interesting case of the intraoperatively diagnosed left-sided gall bladder, where a few minor modifications in laparoscopic technique could salvage the situation with marked improvement in surgical ease and consequent outcomes.

Ectopic gall bladder: A case report

Ectopic gall bladder under the left lobe of liver is a rare congenital anomaly of the position of gall bladder, which is mostly detected during surgery and causes technical difficulty at the time of operation. We operated a 64-year-old male who presented with gall stone disease and pre-operative ultrasound did not report any abnormality in position. On laparoscopy, it was found to be attached on the left side of falciform ligament under segment III. It was a true ectopic gall bladder without situs inversus. Early division of the falciform ligament and a careful and complete dissection of the gall bladder are advocated before clipping the cystic artery and duct to avoid complications. The present case report discusses about this rare anomaly and the available literature on the subject.

Laparoscopic cholecystectomy for left-sided gallbladder

PURPOSE

Left-sided gallbladder (LSGB) is a rare congenital anomaly in the gallbladder, which is defined as a gallbladder located on the left side of the falciform ligament without situs inversus. We retrospectively analyzed 13 patients diagnosed with LSGB in a single center to confirm the safety of laparoscopic cholecystectomy (LC) and reviewed the anatomical implications in those patients.

METHODS

Of the 4910 patients who underwent LC for the treatment of gallbladder disease between August 2007 and December 2019, 13 (0.26%) were diagnosed as having LSGB. We retrospectively analyzed these 13 patients for general characteristics, perioperative outcomes, and other variations through the perioperative imaging workups.

RESULTS

All patients underwent LC for gallbladder disease. In all cases, the gallbladder was located on the left side of the falciform ligament. The operation was successfully performed with standard four-trocar technique, confirming "critical view of safety (CVS)" as usual without two cases (15.4%). In one case, which had an intraoperative complication and needed choledochojejunostomy because of common bile duct injury, there was an associated variation with early common bile duct bifurcation. The other patient underwent an open conversion technique because of severe fibrosis in the Calot's triangle. Furthermore, on postoperative computed tomography, abnormal intrahepatic portal venous branching was found in all cases.

CONCLUSIONS

Although LSGB is usually encountered by chance during surgery, it can be successfully managed through LC with CVS. However, surgeons who find LSGB have to make efforts to be aware of the high risk of bile duct injury and possibility of associated anomalies.

Analysis of right-sided ligamentum teres: The novel anatomical findings and classification

BACKGROUND

The true anatomy of right-sided ligamentum teres (RSLT) has not been fully explained for a century. This study aimed to clarify the exact anatomy of RSLT.

METHODS

The computed tomography data of 17 651 surgical patients were observed and 76 patients with RSLT, were classified into the bilateral ligamentum teres (LT) group (type A) and three RSLT groups, (B) bifurcation type, (C) trifurcation type, and (D) independent posterior branch type.

RESULTS

Type A had double LT that connected to both the right and left sides of the umbilical portion (UP). Types B-D had a P3 + 4 rather than a left UP. Type D was anatomically different from types A-C. Upon comparing types A-C and type D, type D had a significantly smaller volume of segments 3 + 4 (P < .001), and the UP was more often on the left side. The position of the gallbladder fundus in type D was more commonly observed on the right side of the LT compared with that observed in the other types (P = .007).

CONCLUSIONS

The change in the volume of segments 3 + 4 and the extent of the RSLT shift create a false perception that the gallbladder changes the position.

Left-sided gallbladder (LSG) associated with true diverticulum, a case report

The left-sided gallbladder (LSG) is a rare type of anatomical variation (ectopia) defined by the location of the bladder to the left side of the liver falciform and round ligaments. Initially reported in 1886 by Hochstetter, the finding is usually accidental since it is mostly an asymptomatic condition, thus not causing the patient any harm and being few reported cases in the current literature. Surgical cases are most associated with gallstones such as presented in this case report. Our patient was a 60-year-old man from Manaus who presented with symptomatic acute cholelithiasis submitted to laparoscopic cholecystectomy which allowed the visualization of true LSG concomitant with a polyp suggestive lesion. A diagnosis post-cholecystectomy of true gallbladder diverticulum was confirmed by histopathological analysis. Being one of three types of LSG, true LSG is more associated with other structural changes in the biliary tree and also some liver changes, in our case we identified no such alterations. True gallbladder diverticulum has, as the main characteristic, the herniation of all tissues of the gallbladder wall. When presented with LSG, is important to correctly identify the altered structures and adjust the surgical technique in the best way possible, it is up to the surgeon to adapt to the situation presented and ensure the best treatment for his patient.

A Rare Case of a Left-sided Gallbladder Accompanied with an Aplastic Cystic Duct in a Patient with Acute Cholecystitis

BACKGROUND A left-sided gallbladder without situs inversus is a rare congenital anomaly of the gallbladder with a prevalence ranging from 0.04-0.3%. CASE REPORT We present a case of a female patient, referred to our clinic with clinical features of an acute cholecystitis. After performing the standard preoperative investigations, which confirmed the diagnosis, the patient underwent a laparoscopic cholecystectomy. We found a left-sided gallbladder, attached to the lower surface of the left lobe of the liver. During the dissection in the Callot triangle an aplastic cystic duct was also identified. The extirpation of the gallbladder was performed anterograde, allowing a better exposition of the critical structures. CONCLUSIONS A left sided gallbladder is almost an incidental finding, which can be accompanied with further anomalies of the biliary tree. A combination of these 2 variations is very rare without any other reported cases in the literature.

A case of perihilar cholangiocarcinoma with bilateral ligamentum teres hepatis treated with hepatopancreatoduodenectomy

Background

Bilateral ligamentum teres (BLT) hepatis is a very rare anomaly defined as the connection of the bilateral fetal umbilical veins to both sides of the paramedian trunk, and it has never been reported in the English literature.

Case presentation

A 72-year-old man who presented with obstructive jaundice was referred to our hospital. Contrast-enhanced computed tomography revealed that the patient had right-sided ligamentum teres (RSLT) and left-sided ligamentum teres (LSLT). The umbilical portion of the left portal vein, which the LSLT connected, became relatively atrophic in this patient. The RSLT attached to the tip of the right anterior pedicle and formed the umbilical portion of the right portal vein. The patient was diagnosed with perihilar cholangiocarcinoma which had invaded the root of the posterior branch of the bile duct, LHD, and intrapancreatic bile duct. The central bisectionectomy, in which the liver parenchyma was resected along the RHV on the right side and the LSLT on the left side, and caudate lobectomy combined with pancreatoduodenectomy were performed.

The presence of the patient with BLT is important for ascertaining the mechanism of the development of RSLT. Two umbilical veins are present initially during the embryonic stage. In general, the right-sided vein disappears, and the atrophic left-sided vein remains connected to the left portal vein originating from the vitelline vein. Several papers on the mechanism of the development of RSLT have been published. Some authors have mentioned that a residue of the right umbilical vein and the disappearance of the left umbilical vein are the causes of RSLT. On the other hand, some authors have asserted that RSLT is the result of atrophy of the medial liver area. The presence of BLT in patients indicates that the mechanism of the development of RSLT is characterized by a residue of the right umbilical vein and the disappearance of the left umbilical vein.

Conclusions

The mechanism and origin of RSLT can be understood through cases of BLT, and surgeons must pay attention to anomalies of the portal and hepatic veins in patients with abnormal ligamentum teres.

Clinical significance and characteristics of left-sided gallbladder: case series study of 10 patients

Purpose

The aims of this case series study were to review the 10 patients who were diagnosed with left-sided gallbladder and analyze their anatomic variations in the bile duct, portal vein, and hepatic vessels.

Methods

In this case series study, 10 patients with left-sided gallbladder were retrospectively analyzed at 2 tertiary referral centers between April 2004 and May 2019.

Results

Mean age was 61.1 years; there were 7 women and 3 men. Ten patients underwent laparoscopic cholecystectomy for acute cholecystitis or symptomatic gallbladder stone. The mean operation time was 77.2 minutes. Three ports were used in laparoscopic cholecystectomy procedures. The mean postoperative hospital stay was 3.5 days, and there were no cases of surgery-related morbidity. Two patients had type 1 bile duct and 3 had type 3 bile duct (2 type 3B and 1 type 3A). The right posterior portal vein as the first branch of the main portal vein was observed in all patients. Segment IV branches of the left portal vein crossing over to the segment VIII territory were observed in 7 of the 10 patients.

Conclusion

Although left-sided gallbladder is a very rare disease, it is possible to diagnose it preoperatively and perform laparoscopic cholecystectomy safely by adjusting port position. The common important features of left-sided gallbladder include distribution of the left portal vein crossing over to the right side of the liver and increased size of the left portal vein. These variations may have important clinical implications in the management of hepatic resection including donor hepatectomy.

Left-sided gallbladder: a systematic review of a rare biliary anomaly

BACKGROUND

A left-sided gallbladder (LSGB) is a rare anatomical anomaly that is often not discovered until surgery. Two cases of LSGB managed with laparoscopic cholecystectomy (LC) stimulated this systematic review. The aims of this study were in LSGB to define the rate of pre-operative detection, variations in biliary anatomy, laparoscopic techniques employed and outcomes of surgery for symptomatic gallstones.

METHODS

A systematic review was performed using Preferred Reporting Items for Systematic reviews and Meta-Analyses principles.

RESULTS

Fifty-three studies with 112 patients of which 90 (80.4%) had symptomatic gallstones. Pre-operative imaging was performed in 108 patients (96.4%) with an LSGB reported on imaging in 32 (29.6%) patients. The remainder of LSGB were discovered at surgery. Ultrasound detected an LSGB in three (2.7%) patients. Five variants of cystic union with the common hepatic duct (CHD) were identified. The most common (67.8%) was union on the right side of the CHD after a hairpin bend anterior to the CHD. A cholecystectomy for gallstone disease was performed in 90 patients, 23.3% open and 76.7% LC. Common variations in LC technique were different port site placement and techniques related to the falciform ligament to improve exposure. Common bile duct injury occurred in four (4.4%) patients.

CONCLUSION

LSGB is a rare anatomical variation that in patients with symptomatic gallstones is usually discovered at surgery. Cholecystectomy is associated with a higher incidence of common bile duct injury.

Is right-sided ligamentum teres hepatis always accompanied by left-sided gallbladder? Case reports and literature review

Right-sided ligamentum teres (RSLT) hepatis is a rare anatomical variant in which the fetal umbilical vein is connected to the right paramedian trunk of the portal vein. Despite its rarity, it is crucial for surgeons and intervention specialists because of its frequent association with intrahepatic vascular and biliary anomalies. Inattention to these anomalies before intervention, especially living-donor liver transplantation, can have life-threatening consequences. The relationship between gallbladder location and RSLT is still controversial, with RSLT regarded as one of the critical features of left-sided gallbladder in most studies. According to these hypotheses, once RSLT is present, left-sided gallbladder must be found as well. Here, we report three cases in which RSLT was associated with intrahepatic portal vein anomalies. In one case, the gallbladder was left-sided, but in the other two cases, it had a normal cholecystic axis to the right of the umbilical fissure. Therefore, the relationship between RSLT and gallbladder location may require redefinition, and surgeons should be aware of vascular anomalies once RSLT has been detected, even in the absence of left-sided gallbladder or biliary anomalies. TEACHING POINTS: • Right-sided ligamentum teres (RSLT) hepatis is a rare anatomical variant, which is frequently associated with intrahepatic vascular and biliary anomalies. Previous studies had discussed the vascular anomalies in livers with RSLT. • However, no predictable correlation exists between portal vein anomalies and anomalous biliary confluences in patients with RSLT. Moreover, we found that RSLT does not always coexist with left-sided gallbladder. • Unawareness of these vascular and biliary anomalies in liver with RSLT before intervention can have life-threatening consequences. • Thus, the vascular and biliary variations should be surveyed in multimodality imaging studies such as dynamic CT, 3D magnetic resonance cholangiopancreatography, or digital subtraction angiography once the RSLT is detected before intervention.

True left-sided gallbladder: A case report and comparison with the literature for the different techniques of laparoscopic cholecystectomy for such anomalies

•

True LSG is a rare anomaly that may present with right-sided abdominal symptoms and may be missed by preoperative imaging.

•

Though right-sided ports are feasible in LSG, modifications to surgical technique may be done for safe dissection.

•

Meticulous dissection of the gallbladder border is necessary to avoid injury to surrounding tissues.

Introduction

True left-sided gallbladder (LSG) is a rare finding that may present with symptoms similar to those of a normally positioned gallbladder. Moreover, it may be missed by preoperative imaging studies such as ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), or endoscopic ultrasound. True left-sided gallbladder is a surgical challenge and surgical technique may need to be modified for the completion of laparoscopic cholecystectomy.

Presentation of case

In this case report, we present a case of true left-sided gallbladder that produced right-sided abdominal symptoms. Ultrasound of the abdomen failed to show the left-sided position of the gallbladder. MRI showed the gallbladder located to the left of the ligamentum teres underneath segment III of the liver. Intraoperatively, the gallbladder was grasped and retracted to the right under the falciform ligament and it was removed using classical right-sided ports with no modification to the technique. No complications were encountered intraoperatively or postoperatively.

Discussion

True LSG is a rare anomaly that may present with right-sided symptoms like normally positioned gallbladder. It may be missed in preoperative imaging studies and can be discovered only intraoperatively. Modification of laparoscopic ports, change in patient’s position and/or surgeon’s position, or conversion to open cholecystectomy may be needed for safe removal of the gallbladder.

Conclusion

Classical technique of laparoscopic cholecystectomy is feasible for left-sided gallbladder. However, if the anatomy is not clear, modifications of the surgical technique may be necessary for the safe dissection of the gallbladder.

Implications of Left-sided Gallbladder in the Emergency Setting: Retrospective Review and Top Tips for Safe Laparoscopic Cholecystectomy

BACKGROUND

Left-sided gallbladder without situs viscerum inversus (LSG-woSVI) is a rare congenital anomaly. Clinical features and routine presurgical imaging could miss the anomalous position, thereby producing complications during surgery. Laparoscopic cholecystectomy can be performed safely, but the risk of bile duct injury (BDI) is greater than in cholecystectomy of the orthotopic gallbladder. We present a retrospective review of all scientific literature for diagnosed cases of LSG-woSVI undergoing cholecystectomy from 1996 to 2014. Our objectives were to outline empirical top tips for a safe cholecystectomy in incidentally diagnosed LSG-woSVI.

METHODS

We carried a comprehensive search of PubMed using medical subject headings "left-sided gallbladder," "right-sided ligamentum teres" "situs viscerun inversus," "preoperative diagnoses," "cholecystectomy," and "bile duct injury." We considered a classification of the LSG-woSVI in 2 groups: True LSG-woSVI and LSG-woSVI in patients with right-sided ligamentum teres.

RESULTS

Our retrospective review revealed 55 cases of LSG-woSVI. The mean age was 51 years ±17 SD, male/female ratio was 2:1, clinical presentation was pain in the right upper abdominal quadrant in 75.5%, preoperative diagnosis was reached in 16.3%, True LSG was diagnosed in 83%, acute cholecystitis was found in 50%, laparoscopic cholecystectomy was performed in 79.6%, fundus-first dissection technique was used in 16.7%, intraoperative cholangiography was performed in 39.1%, and BDI occurred in 7.3% of the reported cases.

CONCLUSIONS

Increased awareness of the anatomic aberrations in LSG-woSVI associated with improved preoperative diagnosis and a good knowledge about safe surgical techniques for cholecystectomy could indubitably reduce the incidence of BDI.

Major hepatectomy using the glissonean approach in cases of right umbilical portion

Right umbilical portion (RUP) is a rare congenital anomaly associated with anomalous ramifications of the hepatic vessels and biliary system. As such, major hepatectomy requires a careful approach. We describe the usefulness of the Glissonean approach in two patients with vessel anomalies, such as RUP. The first patient underwent a right anterior sectionectomy for intrahepatic cholangiocarcinoma. We encircled several Glissonean pedicles that entered the right anterior section along the right side of the RUP. We temporarily clamped each pedicle, confirmed the demarcation area, and finally cut them. The operation was performed safely and was successful. The second patient underwent a left trisectionectomy for perihilar cholangiocarcinoma. We secured the right posterior Glissonean pedicle. The vessels in the pedicle were preserved, and the other vessels and contents were resected. Identifying the vessels for preservation facilitated the safe lymphadenectomy and dissection of the vessels to be resected. We successfully performed the operation.

Left Sided Gallbladder - Case Report

Left sided gallbladder is a rare anomaly that is often associated with other abnormal anatomy in the hepatobiliary system. One left positioned gallbladder was found in a consecutive series of 3290 patients undergoing laparoscopic cholecystectomy for gallstone disease in the Mure County Emergency Hospital’s 2nd Surgery Clinic between 2005 and 2015, a prevalence of 0.03 per cent. In case of left sided gallbladder the cystic artery always crosses in front of the common bile duct from right to left. The cystic duct may open on the left or right side of the common hepatic duct. Anterograde cholecystectomy is the best choice for precise exploration of the cystic duct and cystic artery.

Left-sided Gallbladder in the Era of Laparoscopic Cholecystectomy: A Single-center Experience

The malposition of gallbladder under the liver segment III, defined as left-sided gallbladder (LSG), is an unexpected situation for the laparoscopic surgeon. The purpose of this study is to present our experience in treating patients with cholecystitis and LSG discovered incidentally during laparoscopic surgical procedure. Between 1993 and 2009, 5569 patients underwent laparoscopic cholecystectomy in our surgical department. Their records were reviewed and seven patients revealed having LSG (0.12%). Analysis parameters included demographic data, diagnostic methods, mode of surgery, and postoperative outcome. Mean follow-up was 140 months. Of the seven patients, five were women. Mean patient age was 56.7 years. All patients were referred to our department with clinical symptoms of classic cholelithiasis and the diagnosis was established in all of them during surgery. Laparoscopic cholecystectomy was successful in five patients, while in two patients, a conversion to open procedure was needed. A postoperative complication, i.e., biliary leakage was registered in one patient, which was treated successfully. Laparoscopic cholecystectomy is safe even in LSG, but the surgeon must consider the possibility for more anatomical anomalies, adjust the technique of dissection, and must not hesitate, if in doubt, to strive for conversion to open procedure to avoid serious complications.

Methods of safe laparoscopic cholecystectomy for left-sided (sinistroposition) gallbladder: A report of two cases and a review of safe techniques

INTRODUCTION

Left-sided gallbladder is a rare anatomical variation. Usually it is discovered intra-operatively and is accompanied by anatomic variations that can prove quite challenging during laparoscopy.

PRESENTATION OF CASE

From a total of almost 3000 laparoscopic cholecystectomies performed in our institution, two cases of left sided gallbladder were unexpectantly identified intraoperatively. There were no indications for the ectopy preoperatively. In both cases modifications of the standard laparoscopic technique were mandatory. They were performed safely with no post-operative complications. Modifications consisted of transposition of the subxiphoid entry port and alteration in the direction of traction of the rest of the graspers. A review of the literature for methods of safe laparoscopic cholecystectomy was conducted.

DISCUSSION

The surgeon must be aware of the anatomic variances in the rare occasion of a left sided gallbladder, since preoperative diagnosis is very difficult.

CONCLUSION

Knowledge of potential hazards and modifications of laparoscopic technique is mandatory in order to avoid complications.

Laparoscopic cholecystectomy for a left-sided gallbladder

Cholecystectomy is a common procedure. Abnormalities in the anatomy of the biliary system are common but an abnormal location of the gallbladder is much rarer. Despite frequent pre-operative imaging, the aberrant location of the gallbladder is commonly discovered at surgery. This article presents a case of a patient with the gallbladder located to the left of the falciform ligament in the absence of situs inversus totalis that presented with right upper quadrant pain. A laparoscopic cholecystectomy was performed and it was noted that the cystic duct originated from the right side. The presence of a left sided gall bladder is often associated with various biliary, portal venous and other anomalies that might lead to intra-operative injuries. The spectrum of unusual positions and anatomical gallbladder abnormalities is reviewed in order to facilitate elective and emergent cholecystectomy as well as other hepatobiliary procedures. With proper identification of the anatomy, minimally invasive approaches are still considered safe.

Ptotic gall bladder with hepatic masses: a case report

Gall bladder (GB) may be found in a variety of abnormal positions. Most of them are due to arrested development of embryonic growth at different stages. A 63-year-old female patient was admitted to our radiology unit for magnetic resonance imaging (MRI) of the liver for the lesions identified in abdominal ultrasonography (US) and computed tomography (CT). MRI showed that there was a lobulated heterogenous mass in the left lobe of the liver and a smaller one in the right lobe of the liver with the same appearance. The inferior pole of the liver was located in the pelvic space, and the GB, which contained sludges and stones, was lying down to the upper pelvic space. Hepatic masses were considered to be hemangiomas, and GB was diagnosed as ptotic GB with luminal sludge and stones. In this case, especially, MR imaging helped the surgeon to plan a proper approach to the GB in abnormal localization.

Surgical implications of a left-sided gallbladder

BACKGROUND

A left-sided gallbladder in a normally positioned liver is considered to be a very uncommon anomaly. Laparoscopic cholecystectomy can be performed safely, but bile duct injury is not unusual. It is associated with anomalous intrahepatic portal and biliary systems which impacts any form of partial hepatectomy.

METHODS

We performed a retrospective review of patients with left-sided gallbladder who were managed by the hepatobiliary surgeons at our institution since 1996.

RESULTS

Nineteen patients with left-sided gallbladder underwent a hepatobiliary procedure. Of the 13 patients with gallstones, only 1 was diagnosed before cholecystectomy. Nine operations were completed laparoscopically, whereas 4 required an open procedure. Two patients were referred with bile duct injuries. There was 1 liver resection for a colorectal metastasis. Left-sided gallbladders in 3 deceased organ donors resulted in major implications in the performance of liver transplantation.

CONCLUSIONS

Left-sided gallbladders are probably more common than generally believed but are rarely diagnosed before cholecystectomy. Associated bile duct injury appears to be not infrequent. Because of the aberrant vasculobiliary anatomy, any form of liver resection requires careful planning.

Liver segment IV hypoplasia as a risk factor for bile duct injury

INTRODUCTION

Bile duct injury remains constant in the era of laparoscopic cholecystectomy and misidentification of structures remains one of the most common causes of such injuries. Abnormalities in liver segment IV, which is fully visible during laparoscopic cholecystectomy, may contribute to misidentification as proposed herein.

METHODS

We describe the case of a 36-year-old female who had a bile duct injury during a laparoscopic cholecystectomy where the surgeon noticed an unusually small distance between the gallbladder and the round ligament.

RESULTS

We define hypoplasia of liver segment IV as well as describe the variation of the biliary anatomy in the case. We also intend to fit it in a broader spectrum of developmental anomalies that have both hyopoplasia of some portion of the liver and variations in gallbladder and bile duct anatomy that may contribute to bile duct injury.

DISCUSSION

To our knowledge, hypoplasia of liver segment IV has not been suggested in the literature as a risk factor for bile duct injury except in the extreme case of a left-sided gallbladder. Surgeons should be vigilant during laparoscopic cholecystectomy when they become aware of an unusually small distance between the gallbladder bed and the round ligament prior to beginning their dissection, variations in the common bile duct and cystic duct should be expected.

Left-sided gallbladder discovered during laparoscopic cholecystectomy in a patient with dextrocardia

Left-sided gallbladder, a rare congenital anomaly, is often associated with transposition of single or multiple viscera of thorax and/or abdomen. Clinical features and routine presurgical ultrasonography could miss the anomalous position thereby producing unnecessary anxiety during surgery. Here we are reporting a patient with left-sided gallbladder, known to have dextrocardia with multiple intracardiac anomalies, and detected incidentally in a series of 1258 consecutive laparoscopic cholecystectomies. Laparoscopic cholecystectomy was performed successfully in this patient with port site modification and careful dissection. Some degree of abdominal visceral situs inversus is to be anticipated in patients with dextrocardia.

Common bile duct injury following laparoscopic cholecystectomy in the setting of sinistroposition of the galladder and biliary confluence: a case report

INTRODUCTION

A bile duct injury occurred to a 64-year-old female with highly aberrant bile ducts due to sinistroposition. Methods of potential injury avoidance are discussed.

MATERIALS AND METHODS

A patient underwent elective laparoscopic cholecystectomy for symptomatic cholelithiasis. A left-sided gallbladder was diagnosed intraoperatively. Three days later, the patient presented with jaundice and rising liver function tests. The patient was referred to our institution for suspected bile duct injury. Endoscopic retrograde cholangiopancreatography showed complete occlusion of the common bile duct. A percutaneous transhepatic tube was placed in the bile ducts for decompression. During later operative exploration, a left-sided common hepatic duct was discovered. Review of preoperative imaging confirmed that the right hepatic duct crossed superior to the umbilical portion of the left portal vein and that segment 4 ducts drained into the right anterior sectional bile duct.

CONCLUSION

This case describes an extremely rare anomaly associated with an injury to the common bile duct during laparoscopic cholecystectomy. Knowledge of the complex and unusual alterations in biliary anatomy, which may accompany sinistroposition of the gallbladder, should aid in avoidance of such injuries in the future.

Aberrant presentation of the gallbladder during laparoscopic cholecystectomy

A left aberrant gallbladder is a rare presentation that requires awareness of biliary anatomy and selective use of intraoperative cholangiography to assist in safe laparoscopic gallbladder resection.

Background:

Aberrant gallbladder transposed to the left side is a rare congenital anomaly that has been seen in as many as 0.7% of the population. These gallbladders are situated under the left lobe of the liver between Segment III and IV and to the left of the falciform ligament. Many preoperative studies fail to identify the anomaly, causing confusion to the surgeon during laparoscopic resection. Selective use of intraoperative cholangiography and meticulous dissection can aid in safe resection.

Methods:

A 61-year-old female was admitted with ultra-sound confirmation of cholecystitis and subsequently taken to the operating room for a laparoscopic cholecystectomy.

Results:

Evaluation of the gallbladder under laparoscopic view revealed an inflamed left aberrant gallbladder. An intraoperative cholangiogram was obtained to delineate the biliary anatomy that showed the cystic duct entering the common hepatic duct on the right side.

Conclusion:

A left aberrant gallbladder is a rare presentation that requires awareness of biliary anatomy and selective use of intraoperative cholangiography to aid in the safe laparoscopic resection of the gallbladder.

Left-sided gallbladder: a complicated percutaneous cholecystostomy and subsequent hepatic embolisation

A 68-year-old male patient with chronic hypertension, diabetes mellitus and chronic renal failure was diagnosed with acute calculous cholecystitis. A percutaneous cholecystostomy using a transperitoneal approach was performed after two failed attempts with a right-sided transhepatic approach. Subsequent hepatic embolisation was performed for the treatment of haemoperitoneum due to hepatic injury after the percutaneous cholecystostomy. The presence of a left-sided gallbladder was confirmed by laparoscopic cholecystectomy after 1 week. Prior identification of this anomaly would have prevented hepatic injury through the use of a cautious procedure against mobility or careful selection of the approach routes. In conclusion, the transperitoneal approach can be easier or more preferable to perform for a percutaneous cholecystostomy of a left-sided gallbladder.

Left-sided gallbladder with right-sided ligamentum teres hepatis: rare associated anomaly of exomphalos

PURPOSE

The aim of this investigation was to establish the association of left-sided gallbladder and right-sided ligamentum teres hepatis with exomphalos and to clarify the portal venous anomaly associated with right-sided ligamentum teres.

METHODS

Three male infants with exomphalos major associated with left-sided gallbladder and right-sided ligamentum teres hepatis were identified during a retrospective study of exomphalos cases (n = 35) in which exomphalos major comprised 18 cases over 19 years.

RESULTS

Three infants with exomphalos major (8.6%) had a left-sided gallbladder and right-sided ligamentum teres hepatis. One male infant survived. Computed tomography showed that there is anomalous intrahepatic portal venous branching associated with right-sided ligamentum teres hepatis. The first branch of the portal vein ran to the right posterior segment, and then the portal vein formed a trunk of the left portal vein and right anterior portal veins. The latter vein formed the umbilical segment of the portal vein and finally joined the ligamentum teres hepatis. The inferior vena cava was on the left side below the kidney and crossed to the right side at the level of the kidney.

CONCLUSIONS

Left-sided gallbladder with right-sided ligamentum teres hepatis may not be such a rare associated anomaly in infants with exomphalos. However, there are no reports describing this anomaly with exomphalos in the English medical literature. We believe this is the first report. As long-term survival after repair of exomphalos is increasing, perhaps some of the survivors may develop liver disease which requires liver resection later in life. Recognition of this anomalous relationship with exomphalos is clinically important because it is associated with abnormal intrahepatic portal venous branching and intraabdominal vascular anomalies.

Left-sided gallbladder: Its clinical significance and imaging presentations

AIM: To assess the importance of preoperative diagnosis and presentation of left-sided gallbladder using ultrasound (US), CT and angiography.

METHODS: Retrospective review of 1482 patients who underwent enhanced CT scanning was performed. Left-sided gallbladder was diagnosed if a right-sided ligamentum teres was present. The image presentations on US, CT and angiography were also reviewed.

RESULTS: Left-sided gallbladder was diagnosed in nine patients. The associated abnormalities on CT imaging included portal vein anomalies, absence of umbilical portion of the portal vein in the left lobe of the liver, club-shaped portal vein in the right lobe of the liver, and difficulty in identifying segment IV. Angiography in six of nine patients demonstrated abnormal portal venous system (trifurcation type in four of six patients). The main hepatic arteries followed the portal veins in all six patients. The segment IV artery was identified in four of six patients using angiography, although segment IV was difficult to define on CT imaging. Hepatectomy was performed in three patients with concomitant liver tumor and the diagnosis of left-sided gallbladder was confirmed intraoperatively.

CONCLUSION: Left-sided gallbladder is an important clinical entity in hepatectomy due to its associated portal venous and biliary anomalies. It should be considered in US, CT and angiography images that demonstrate no definite segment IV, absence of umbilical portion of the portal vein in the left lobe, and club-shaped right anterior portal vein.

[Anatomy of the liver: what you need to know]

A precise knowledge of arterial, portal, hepatic and biliary anatomical variations is mandatory when a liver intervention is planned. However, only certain variations must be searched when a precise intervention is planned. The basic liver anatomy as well as the most relevant malformations will be precised.

Left-sided gallbladder associated with congenital liver cyst

BACKGROUND

A left-sided gallbladder is a rare congenital anomaly defined as a gallbladder attached to the lower surface of the left lateral segment of the liver, i.e. to the left of the interlobar fissure and round ligament.

CASE OUTLINES

In two women aged 42 and 70 years a left-sided gallbladder was associated with a congenital cyst of the liver. In the first patient, the ectopic gallbladder was an incidental finding at operation for a symptomatic liver cyst; as the gallbladder was normal it was not removed. The second patient underwent operation for chronic calculous cholecystitis, when the left-sided gallbladder and congenital liver cyst were found. An operative cholangiogram was normal, the cystic duct joining the common bile duct from the right side. The gallbladder was removed, and the cyst was de-roofed. Both patients had an uneventful recovery and remain symptom-free at 12 and 9 years respectively.

DISCUSSION

To the best of our knowledge, the association of these two congenital anomalies has not been described previously.

Fusion of the planes of the liver: an anatomic entity merging the midplane and the left intersectional plane

BACKGROUND

Alignment of the gallbladder fossa and the round ligament may be associated with an almost unknown portal vein branching anomaly.

STUDY DESIGN

Ultrasonographic imaging allowed detection of this anomaly, which we characterized as fusion of the planes of the liver. When appropriate, additional specific radiologic examinations were performed (CT scanner supplemented with a three-dimensional reconstruction, a biliary cartography, or an angiography). Surgical consequences were studied from this series and from the literature.

RESULTS

Seven patients (0.5%) had the following criteria: 1) round ligament, gallbladder fossa, and termination of the portal vein occurring in the same plane; 2) typical portal vein branching, including a right posterior branch, left branches, and a main medial branch terminated by the Rex's recessus; 3) two main hepatic veins without a significant middle hepatic vein; and 4) absence of the horizontal part of the left hepatic duct. Fusion of the planes may have been involved in two cases of iatrogenic bile duct injury and contraindicated a tumor resection and a right-liver donation. A review of the literature revealed that lack of recognition of the fusion of the planes led to a high proportion of surgical iatrogenic injury. Fusion of the planes could result from incomplete development of the central part of the liver, in agreement with embryologic knowledge.

CONCLUSIONS

Knowledge of the fusion of the planes by hepato-biliary surgeons is important. This anomaly may lead to serious complications if it remains undetected during liver resection or bile duct surgery.

Laparoscopic Left Hepatic Lobe Cholecystectomy

Left sided gallbladders are rare and this case describes cholecystectomy without additional port placement.

Estudo anatomotopográfico das vias biliares extra hepáticas e do trígono cistohepático

OBJETIVO: Estudar a morfologia do sistema biliar extra-hepático e do trígono cistohepático (triângulo de Calot) analisando a sua disposição, variações ou malformações MÉTODOS: foram investigados 50 cadáveres adultos. RESULTADOS: em 47 casos (94%) a junção hepato-cística se dava próxima ao hilo hepático. Em 3 casos (6%), a junção entre esses ductos se dava distalmente, ao nível da ampola hepato-pancreática (ampola de Vater). O ângulo formado pela junção hepato-cística foi menor que 30º em 72,3% dos casos; em 23,4% , ficou entre 30 e 45º; em 2,1% variou entre 45 e 60º e em 2,1% foi maior do que 60º. A junção hepato-cística se fez, na maior parte dos casos, pela direita (59,6%), seguida pela anterior (17%), posterior (12,8%) e esquerda (10,6%). Em relação aos componentes do trígono cistohepático, a artéria cística esteve presente em 56% dos casos; a veia porta em 36%; a artéria hepática direita em 34%; a artéria hepática esquerda em 2% e a artéria hepática própria em 2% dos casos. O comprimento e o diâmetro do ducto cístico foi 2,53± 1,19cm e 0,29± 0,12cm, respectivamente. A prega espiral do ducto cístico ( válvula de Heister) foi observada em 80% dos casos. O infundíbulo da vesícula biliar (bolsa de Hartmann) esteve presente em 74% dos casos. Esses conhecimentos são importantes, principalmente para os cirurgiões que atuam nesta região, através de videolaparoscopia. CONCLUSÃO: No trígono cistohepático a artéria cística foi encontrada com mais freqüência.