Left-sided gallbladder: an incidental finding on laparoscopic cholecystectomy

Laparoscopic choledochoscopy for choledocholithiasis is possible in the anatomical anomaly of left gallbladder

Laparoscopic cholecystectomy (LC) is more challenging in the anatomical variation of left-sided gallbladder with the anomaly also highly related to biliary anomalies. Therefore, there has been a reluctance to operate close to the common bile duct (CBD) in left gallbladder patients, and thus choledocholithiasis is usually treated with endoscopic retrograde cholangiopancreatography (ERCP). There is emerging evidence that single stage LC and CBD exploration for choledocholithiasis may be superior to two stage LC and ERCP in terms of short-term and long-term morbidity, cost and length of stay. With the re-emergence of laparoscopic choledochoscopy, the purpose of this case report is to demonstrate the feasibility of this approach for choledocholithiasis.

Left sided gallbladder: A case report during laparoscopic cholecystectomy for acute cholecystitis

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Left-sided gallbladder.

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Acute Choleystitis.

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Laparoscopic Cholecystectomy.

Introduction

A true left sided gallbladder (T-LSG) is a rare finding mostly discovered incidentally during laparoscopy and often associated with several anatomic anomalies; surgical approach may be challenging with an increased risk of intra-operative injuries and conversion to open.

Presentation of the case

A 76 years old woman presented with acute cholecystitis. The left sided gallbladder was unexpectedly discovered as an intra-operative finding. Laparoscopic cholecystectomy was carried out using our usual trocar set-up without the need of intra-operative cholangiography or conversion to open.

Discussion

LSG is reported to be associated with a higher risk of intraoperative bile duct injuries (up to 7.3%) due to anomalies of the bile duct, portal vein, and other structures. Achieving the Critical View of Safety by opening Calot’s triangle is essential to avoid bile duct injuries.

Conclusion

Experienced surgeons could safely approach LSG laparoscopically, also in emergency setting, without major changing in their surgical technique with limitation of diathermy use and prudent dissection of anatomical structures to avoid biliary injuries. Intra-operative cholangiography is not mandatory.

1st report of unexpected true left-sided gallbladder treated with robotic approach

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For left-sided gallbladder, no change of port setting is needed using the robot.

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ICG helps to recognize associated vascular and biliary anomalies.

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Anatomical variations assessment is crucial to avoid biliary or vascular injuries.

Introduction

True left-sided gallbladder (T-LSG) occur when the gallbladder is positioned to the left of the ligamentum teres and falciform ligament and under the surface of the left liver lobe.

Presentation of case

Patient is 29-year-old caucasian male, presenting with 9-month history of epigastric right upper quadrant (RUQ) colic pain. RUQ Ultrasound reported cholelithiasis, gallbladder wall thickening, and no intrahepatic biliary dilation.

Discussion

Robotic cholecystectomy was the chosen approach. When visceral surface of the liver was exposed, anomalous location of the gallbladder was noted, left to the round ligament. A cystic duct with a “hairpin” configuration and a very cephalad cystic artery were identified. Cholecystectomy was performed safely and uneventfully.

Conclusion

No change of port setting was required with the robotic approach. The ICG-aided cholangiography improved surgeon’s ability to recognize the concomitant vascular and biliary anomalies. However, no definitive conclusion can be drown until further experience and volume are achieved.

Sinistroposition: A case report of true left-sided gallbladder in a Vietnamese patient

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Left-sided gallbladder without situs viscerum inversus is a rare congenital anomaly.

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Left-sided gallbladder is accompanied by anatomic variations: portal vein and/or biliary system anomalies, segment IV atrophy, variations in hepato-biliary vascular anatomy.

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Left-sided gallbladder can present significant intraoperative challenges due to associated variations in ductal and vessel anatomy.

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There are three proposed, embryologic mechanisms for Left-sided gallbladder without situs viscerum inversus.

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Even the face of routine preoperative testing, ultrasound, and CT scan, left-sided gallbladder often remains undetected until surgery.

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Laparoscopic antegrade cholecystectomy can be performed safely for left-sided gallbladder.

Introduction

Left-sided gallbladder without situs viscerum inversus (LSG-woSVI) is defined as a gallbladder located under the left lobe of the liver; to the left of the round/falciform ligament, but with all other viscera maintaining normal anatomical relationships. This is a rare congenital anomaly with a reported prevalence that ranges from 0.04% to 1.1%. It is usually an incidental intraoperative finding, and can be associated with anatomic abnormalities of the biliary tree, portal system and vasculature. LSG and associated variations may present significant challenges even for experienced surgeon.

Presentation of case

LSG-woSVI was unexpectedly discovered in a 49-year-old, Vietnamese female during laparoscopic cholecystectomy. There were no pre-operative indications of sinistroposition. The cystic duct joined the common hepatic duct on the right side, and the cystic artery crossed anterior to the common bile duct in a right-to-left direction. Antegrade cholecystectomy was performed without intraoperative or postoperative complications.

Discussion

LSG is a rare anatomical variation that often remains undetected with ultrasound and pre-operative tests. Several hypotheses suggest underlying embryologic mechanisms for LSG and associated anomalies in ductal, portal and vascular anatomy, but the exact cause remains a mystery. Safe laparoscopic cholecystectomy can be done; however, there is an increased risk of injury to the major biliary structures compared to orthotopic gallbladder.

Conclusion

Laparoscopic antegrade cholecystectomy is feasible for LSG. However, surgeons need to be cognizant of anatomy, so that rapid modifications of surgical technique can ensure positive patient outcomes.

Gallbladder to the left side of the falciform ligament in absence of Situs Inversus "Sinistroposition" - Case series of 2 patients with this anomaly who underwent mini-laparoscopic cholecystectomy

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Left-sided Gallbladders are considered a rare anatomic anomaly, even though, prevalence is increasing.

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This can be an incidental finding during surgery.

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It is in part due to the fact that radiographic images tipically do not detect them.

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Due to this, surgeons must be aware of this anomaly during surgery.

Introduction

Gallbladders located to the left of falciform ligament, without situs inversus, are denominated sinistroposition or true left-sided gallbladders; it is considered a rare anatomic anomaly with a prevalence in between 0.1% and 0.7%. Left-sided gallbladder usually occur as a component of situs inversus.

Presentation of cases

We report a case series of two patients of true left-sided gallbladder that were found at our institution from 2015 to 2017; the anatomic anomalies were discovered during the performance of mini-laparoscopic cholecystectomy due to acute cholecystitis with cholelithiasis in both cases. Both patients underwent a successful surgery and there were no postsurgical complications.

Discussion

The reported prevalence of left-sided gallbladder is between 0.1% and 0.7%, thus considered a rare anatomic finding. Currently, with advances in diagnostic imaging modalities, the report of left-sided gallbladder has increased nowadays. It may be a more common anomaly than previously thought.

Conclusion

True left-sided gallbladder can be an incidental finding; it is in part due to the fact that radiographic images do not typically detect this anomaly, therefore surgeons must be aware of this condition because it is associated with anomalies in the intrahepatic portal vein and biliary tree.

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.

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

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

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

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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.

Left-sided gallbladder (Sinistroposition) encountered during laparoscopic cholecystectomy: A rare case report and review of the literature

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LSG is a peculiar anatomical variation that is difficult to be identified preoperatively.

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LSG is associated with anatomical anomalies that may lead to intra-operative injuries.

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Safe laparoscopic cholecystectomy is feasible by placing the patient to left-side up position for better exposure of the operative field.

Introduction

True Left-sided gallbladder (LSG) is a rare anatomical variation with a prevalence of 0.3%. Mainly discovered during the operation, its surgical approach in the laparoscopic setting may be challenging even for an experienced surgeon.

Presentation of case

LSG was unexpectedly discovered in a young man during laparoscopic cholecystectomy. There were no pre-operative indications of this sinistroposition. The laparoscopic cholecystectomy was performed with minor surgical modifications and it was uneventful. A meticulous review of recent literature about LSGs was conducted as well.

Discussion

LSG is a scarce anatomical aberration that is difficultly identified pre-operatively. Surgeons should be aware of this aberration and of its accompanying anatomical variations in order to perform a safe laparoscopic cholecystectomy.

Conclusion

Surgeons, by placing the patient to left-side up position, are able to expose the Calot’s triangle and possible accompanying anatomical anomalies and thus perform a safe laparoscopic cholecystectomy without difficult surgical modifications.

Does gallbladder angle affect gallstone formation?

INTRODUCTION

Morphology of gallbladder varies considerably from person to person. We believe that one of the morphological variations of gallbladder is the "gallbladder angle". Gallbladder varies also in "angle", which, to the best of our knowledge, has never been investigated before. The purpose of this study was to investigate the impact of gallbladder angle on gallstone formation.

METHODS

in this study, 1075 abdominal computed tomography (CT) images were retrospectively examined. Patients with completely normal gallbladders were selected. Among these patients, those with both abdominal ultrasound and blood tests were identified in the hospital records and included in the study. Based on the findings of the ultrasound scans, patients were divided into two groups as patients with gallstones and patients without gallstones. Following the measurement of gallbladder angles on the CT images, the groups were statistically evaluated.

RESULTS

The gallbladder angle was smaller in patients with gallstones (49 ± 21 degrees and 53 ± 19 degrees) and the gallbladder with larger angle was 1.015 (1/0.985) times lower the risk of gallstone formation. However, these were not statistically significant (p>0,05).

CONCLUSION

A more vertically positioned gallbladder does not affect gallstone formation. However, a smaller gallbladder angle may facilitate gallstone formation in patients with the risk factors. Gallstones perhaps more easily and earlier develop in gallbladders with a smaller angle.

True left-sided gallbladder with variations of bile duct and cholecystic vein

A left-sided gallbladder without a right-sided round ligament, which is called a true left-sided gallbladder, is extremely rare. A 71-year-old woman was referred to our hospital due to a gallbladder polyp. Computed tomography (CT) revealed not only a gallbladder polyp but also the gallbladder located to the left of the round ligament connected to the left umbilical portion. CT portography revealed that the main portal vein diverged into the right posterior portal vein and the common trunk of the left portal vein and right anterior portal vein. CT cholangiography revealed that the infraportal bile duct of segment 2 joined the common bile duct. Laparoscopic cholecystectomy was performed for a gallbladder polyp, and the intraoperative finding showed that the cholecystic veins joined the round ligament. A true left-sided gallbladder is closely associated with several anomalies; therefore, surgeons encountering a true left-sided gallbladder should be aware of the potential for these anomalies.

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.