Reappraisal of left-sided gallbladder and its accompanying anomalies: a report of two cases and literature review

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.

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.

Hepatectomy for Hilar Cholangiocarcinoma with Right-Sided Ligamentum Teres Using a Hepatectomy Simulation System

Right-sided ligamentum teres (RSLT) is a rare congenital anomaly often accompanied by variation of the hepatic vasculature. We herein report a surgical case of a hilar cholangiocarcinoma with RSLT in whom preoperative hepatectomy simulation proved useful for understanding the anatomical structure of the liver. A 78-year-old male with obstructive jaundice was referred to our department for further examination. The patient was suspected of having a hilar cholangiocarcinoma originating from the left hepatic bile duct by contrast-enhanced computed tomography (CT), and CT also showed right umbilical portion (RUP). Three-dimensional images of the hepatic vasculature and biliary system reconstructed using a hepatectomy simulation system suggested that all portal branches ramified from RUP were right paramedian branches, and three leftward portal branches from these ran parallel to the peripheral bile ducts confluent with the left hepatic bile duct, where the tumor was present. Hepatic resection of part of the ventral area of the right paramedian sector and left hemiliver was performed along the demarcation line drawn after clamping the portal branches; the ratio of estimated liver resection volume was 28.9%. After the operation, bile leakage occurred. However, the leakage was treated with percutaneous drainage alone, and the patient was discharged 77 days after the operation. The patient is doing well without any signs of recurrence 21 months after the operation. The vascular and biliary anatomy in patients with RSLT is complicated and should be evaluated in detail preoperatively using a hepatectomy simulation system.

Spatial anatomy of the round ligament, gallbladder, and intrahepatic vessels in patients with right-sided round ligament of the liver

PURPOSE

To analyze the vascular structure of the liver in patients with a right-sided round ligament.

METHODS

We reviewed 16 patients with a right-sided round ligament and 3 polysplenia and situs inversus patients with a left-sided round ligament who underwent multidetector row CT with contrast media. The patient population consisted of 13 men and 6 women (mean 62 years). We analyzed the axial and volume-rendered images for the location of the round ligament, gallbladder, portal veins, hepatic veins, and hepatic artery. The following imaging findings for the patients with polysplenia and situs inversus were horizontally reversed.

RESULTS

The prevalence of a right-sided round ligament with and without polysplenia was 75 and 0.11 %, respectively. The gallbladder was located to the right, below, and left of the round ligament in 27.7, 38.8 and 33.3 %, respectively. Independent branching of the right posterior portal vein was noted in 57.8 %. PV4 was difficult to identify in 36.8 %. The middle hepatic vein was located to the left of the round ligament. Two branching patterns for the lateral and medial branches of the right anterior hepatic artery were noted: the common (44.4 %) and separated types (55.5 %). Both of the right anterior hepatic artery and portal vein ramified into two segments; the lateral segment with many branches and the medial segment with a few branches.

CONCLUSIONS

The right-sided round ligament divided the right anterior section into the lateral and medial segments based on the portal vein and hepatic artery anatomy.

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.

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.