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

Laparoscopic cholecystectomy for a gallbladder with a short cystic duct draining to the accessory right anterior hepatic duct using indocyanine green fluorescence imaging: A case report

INTRODUCTION

Gallbladder with a short cystic duct draining to the accessory right anterior hepatic duct is a rare variation. It is frequently associated with bile duct injury during laparoscopic cholecystectomy. We present a case of a gallbladder with this variation safely treated with laparoscopic cholecystectomy using indocyanine green (ICG) fluorescence imaging.

PRESENTATION OF CASE

A 57-year-old man had right upper quadrant pain and showed a gallbladder stone on a preoperative computed tomography. Bile duct anomaly was not detected before operation. However, a short cystic duct draining to the accessory right anterior hepatic duct intraoperatively was found using ICG fluorescence imaging. To confirm the exact anatomy, we firstly detached the gallbladder from the liver with a "fundus first technique" and visualized the whole course of the short cystic duct and the accessory right anterior with ICG fluorescence imaging. Laparoscopic cholecystectomy was completed safely. No bile leakage was detected on ICG fluorescence imaging. The patient had no postoperative complication.

DISCUSSION

Accessory right hepatic duct is one of the rare variations of bile duct. It can be related to bile duct injury during laparoscopic cholecystectomy. Although it can be injured easily because of its smaller size, we can identify the short cystic duct from it with the aid of ICG fluorescence imaging without injuring the accessory right anterior hepatic duct.

CONCLUSION

Laparoscopic cholecystectomy for gallbladder with a short cystic duct draining to the accessory right anterior hepatic duct can be safely performed by identifying biliary anatomy with ICG fluorescence imaging.

Indocyanine green (ICG) fluorescence in robotic hepatobiliary surgery: A systematic review

BACKGROUND

Indocyanine green fluorescence (ICG-F) stains hepatic tumours and delineates vascular and biliary structures in real-time. We detail the efficacy of ICG-F in robotic hepatobiliary surgery.

METHODS

PubMed, EMBASE, Web of Science, and Cochrane Central were searched for original articles and meta-analyses detailing the outcomes of ICG-F in robotic hepatobiliary surgery.

RESULTS

214 abstracts were reviewed; 16 studies are presented. One single-institution study reported ICG-F in robotic right hepatectomy reduced postoperative bile leakage (0% vs. 12%, p = 0.023), R1 resection (0% vs. 16%, p = 0.019), and readmission (p = 0.023) without prolonging operative time (288 vs. 272 min, p = 0.778). Improved visualisation aided in attainment of R0 resection in partial hepatectomies and radical gallbladder adenocarcinoma resections. Fewer ICG-F-aided robotic cholecystectomies were converted to open procedure compared to laparoscopic cholecystectomies (2.1% vs. 8.9%, p = 0.03; 0.15% vs. 2.6%, p < 0.001).

CONCLUSIONS

ICG-F improves clinical outcomes in robotic hepatobiliary surgery without prolonging operative time. There is an opportunity to standardise ICG administration protocols, especially for hepatectomies.

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

•

Left-sided gallbladder.

•

Acute Choleystitis.

•

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.

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.

First Report of Gallbladder Volvulus Managed with a Robotic Approach

Gallbladder volvulus (GV) is an axial twisting of the gallbladder (GB). If not treated on time, this condition has a mortality up to 6%. It is usually diagnosed intraoperatively, because it can mimic a typical acute cholecystitis. An 81-year-old female patient presented with an acute onset of right upper quadrant pain accompanied with nausea. The patient was admitted to receive treatment for acute cholecystitis after the findings of ultrasound imaging. Robotic-assisted cholecystectomy was the approach chosen. GV was diagnosed after initial diagnostic laparoscopy. Cholecystectomy was performed uneventfully. Indocyanine green fluorescence was used to assess the biliary anatomy. The postoperatory course went uneventful. The patient was discharged home on postoperatory day 2.