Duplicated gallbladder: an incidental anatomical variation in a patient with symptomatic cholelithiasis

Congenital malformations of the biliary tract represent a relatively rare entity with which surgeons, radiologists and clinicians are not adequately familiarized. We present a rare case of gallbladder duplication in a 40-year-old female, with the accessory cystic duct entering the left hepatic duct, which depicts the fifth reported case in the international bibliography. Our case illustrates the importance of detailed knowledge of anatomical malformations of the biliary tree, serving the purpose of a preoperative diagnosis of symptomatic cholelithiasis. It is also of paramount importance to take under consideration biliary tract malformations to avoid inadvertent complications such as biliary duct injuries in case of laparoscopic cholecystectomy.

Duplication of gallbladder: a rare anomaly of biliary tract- A case report

Incomplete duplication of gall bladder or vesica fellea divisa is one of the rare anomalies of gallbladder. Until now, 25 cases have been reported; of which four were proceeded with laparoscopic cholecystectomy. In our case, we diagnosed this nadir anomaly laparoscopically, posing a technical challenge since no radiological clue was observed beforehand. Successful laparoscopic resection of duplicated gall bladders was performed followed by Magnetic Resonance CholangioPancreaticography.

Duplication of the gallbladder in a patient with right colon cancer. A case report and review of the literature review

AIM

Duplication of the gallbladder is a very rare congenital variant, showing an incidence of about 1 in 4000 in the population, occurring twice as often in women than in men. In the literature only a few cases of prenatal diagnosis are reported. The knowledge of the existence of this anatomical variable is very important in order to avoid complications and iatrogenic damage during interventional and surgical procedures involving the biliary tract or adjacent organs.

CASE REPORT

A 79-year-old patient was admitted to our Hospital in May 2021 presenting abdominal pain. During hospitalization, a 5cm adenocarcinoma of the ascending colon was found. During surgery the known accessory gallbladder was found strongly adhering to the proximal transverse colon. The challenging viscerolysis maneuvers caused a lesion on one of the gallbladders, so we decided to proceed with cholecystectomy of both gallbladders.

RESULTS AND DISCUSSION

Duplication of the gallbladder is a rare congenital anatomical variant and requires special attention to the biliary and arterial anatomy in order to avoid iatrogenic damage. This variant can complicate surgical treatment for complications that need urgent treatment, such as cholecystitis. Currently the technique of choice for the evaluation of the biliary tree is magnetic resonance cholangiography. Laparoscopic cholecystectomy is the treatment of choice.

CONCLUSION

Surgeons should be aware of the different forms of presentation of gallbladder pathologies, also the ones that are not "the standard" of routine. Detailed preoperative study is essential to avoid a missed diagnosis.

KEY WORDS

Gallbladder, Mininvasive surgery, Variant, Anatomical.

Perforated duodenal ulcer in a dog with gallbladder agenesis

Background: Duodenal ulceration (DU) in dogs derives from different causes but has never previously been related to gallbladder agenesis (GA). GA is a rare congenital disorder in dogs and is considered a predisposing factor for DU in humans. Case description: A 5-month-old intact female Maltese was presented for acute vomiting and diarrhea. Abdominal ultrasound suggested duodenal perforation and absence of the gallbladder. Exploratory laparotomy was performed to treat the perforation and confirmed GA. Hepatic ductal plate malformation (DPM) was histologically diagnosed in liver biopsy, but no signs of liver dysfunction were detected by blood work at first admission. Two months later, the dog developed signs of portal hypertension and medical treatment was started. However, the clinical condition gradually worsened until liver failure and the dog was euthanized 8 months after surgery. Necropsy confirmed hepatic abnormalities. Conclusion: This report describes a case of DU associated with GA and DPM in a dog. As in humans, GA may represent a hepatobiliary disease predisposing to gastroduodenal ulcerations.

Multiseptate gallbladder: A case report and literature review

RATIONALE

Multiseptate gallbladder (MSG) is a rare congenital gallbladder anomaly. Between 1963 and June 2021, only 56 cases were reported. There is currently no treatment guideline for pediatric or adult cases of MSG.

PATIENT CONCERNS

A 14-year-old woman visited our out-patient clinic in September 2020 for epigastric pain that last for 6 months. Honeycomb appearance of the gallbladder was noted under ultrasonography.

DIAGNOSIS

The patient was diagnosed with MSG. The diagnosis was confirmed through computed tomography and magnetic resonance cholangiopancreatography.

INTERVENTIONS

Cholecystectomy was performed.

OUTCOMES

Epigastric pain showed limited improvement after the surgery. Since she was diagnosed with gastritis at the same time, a proton-pump inhibitor was prescribed. Epigastric pain was eventually resolved.

LESSONS

MSG cases can undergo cholecystectomy and show good recovery without complications. However, concomitant treatment may be required to resolve in the presence of other symptoms such as epigastric pain.

Hepatic hilum-type II choledochal cyst masquerading as gallbladder duplication

Choledochal cyst and gallbladder duplication are rare congenital anomalies. They typically are surgical problems of infancy or childhood but rarely may present in adults also. Despite high resolution imaging, the differentiation of type II choledochal cyst from gallbladder duplication often causes the diagnostic dilemma; which may result in high risk for intraoperative iatrogenic injury. Operative management of choledochal cyst is the definite treatment because of its malignant potential. A type II choledochal cyst arising from the hepatic hilum presenting as gallbladder duplication on imaging has not been reported earlier in the literature and here we present a case report of the same which was managed successfully.

Urgent cholecystectomy in patient with left-sided gallbladder Case report and review of the literature

INTRODUCTION

Sinistroposition of the gallbladder, or true left-sided gallbladder (LSG) without situs viscerum inversus, is a rare congenital anatomical variant where the gallbladder is located to the left of round/falciform ligament. It can be associated with anomalies of the biliary tree, portal system and hepatic vascularization. The surgical management of a LSG could be challenging even for an experienced operator, being usually an incidental intraoperative finding.

CASE REPORT

A 72 years old woman was admitted to our emergency department because of acute cholecystitis. There were no pre-operative indications of sinistroposition of the gallbladder and its aberrant position was discovered during the explorative laparoscopy; because of the unusual anatomy and chronic flogosis, the laparoscopic approach was converted to open surgery. The patient underwent a successful intervention and was discharged after 4 days without complications. Her family history revealed a daughter with biliary atresia.

DISCUSSION

LSG could remain undetected at preoperative imaging, but today, with advances in diagnostic imaging, the report of this condition has increased. Several hypothesis suggest the presence of an underlying embriologic mechanism for LSG and its associated anomalies, but its etiology is still unknown. The association with the daughter's biliary atresia makes reasonable a possible genetic correlation with this condition.

CONCLUSIONS

In case of LSG, laparoscopic cholecystectomy could be feasible and safe, but with an increased risk of injury to the major biliary structures, mostly in case of severe and chronic inflammation of the gallbladder. Surgeons have to know this variant because of its associated hepatic anomalies.

KEY WORDS

Cholecystectomy, Emergency Surgery, Left-Sided-Gallbladder.

Gallbladder wall abnormality in biliary atresia of mouse Sox17+/- neonates and human infants

Biliary atresia (BA) is characterized by the inflammation and obstruction of the extrahepatic bile ducts (EHBDs) in newborn infants. SOX17 is a master regulator of fetal EHBD formation. In mouse Sox17+/- BA models, SOX17 reduction causes cell-autonomous epithelial shedding together with the ectopic appearance of SOX9-positive cystic duct-like epithelia in the gallbladder walls, resulting in BA-like symptoms during the perinatal period. However, the similarities with human BA gallbladders are still unclear. In the present study, we conducted phenotypic analysis of Sox17+/- BA neonate mice, in order to compare with the gallbladder wall phenotype of human BA infants. The most characteristic phenotype of the Sox17+/- BA gallbladders is the ectopic appearance of SOX9-positive peribiliary glands (PBGs), so-called pseudopyloric glands (PPGs). Next, we examined SOX17/SOX9 expression profiles of human gallbladders in 13 BA infants. Among them, five BA cases showed a loss or drastic reduction of SOX17-positive signals throughout the whole region of gallbladder epithelia (SOX17-low group). Even in the remaining eight gallbladders (SOX17-high group), the epithelial cells near the decidual sites were frequently reduced in the SOX17-positive signal intensity. Most interestingly, the most characteristic phenotype of human BA gallbladders is the increased density of PBG/PPG-like glands in the gallbladder body, especially near the epithelial decidual site, indicating that PBG/PPG formation is a common phenotype between human BA and mouse Sox17+/- BA gallbladders. These findings provide the first evidence of the potential contribution of SOX17 reduction and PBG/PPG formation to the early pathogenesis of human BA gallbladders.This article has an associated First Person interview with the joint first authors of the paper.

Complete laparoscopic cholecystectomy for a duplicated gallbladder: A case report

INTRODUCTION

Duplication of the gallbladder (GB) is a rare congenital abnormality occurring in 1 in 4000 to 5000 births. Three types have been reported: type I (split primordial GB), type II (2 separate GBs with their own cystic ducts), and type III (triple GBs drained by 1 to 3 separate cystic ducts). Patients with a duplicated GB are usually asymptomatic and are sometimes not diagnosed on preoperative imaging, which might increase the difficulty and risk of cholecystectomy. The key to successful treatment is total removal of the duplicated GB to avoid the recurrence of disease. Intraoperative cholangiography is recommended for identifying and resecting duplicated GBs. The final diagnosis depends on the histopathology.

PATIENT CONCERNS

A 62-year-old woman had recurrent upper abdominal pain and nausea for 1 year, with no fever, jaundice, or other symptoms. An ultrasound of the abdomen indicated polyps in the GB. Computed tomography (CT) revealed moderate dense structures attached to the wall of the GB and an unusual 47 × 21 mm elliptical structure with an extra tubule located above the main GB.

DIAGNOSIS

A diagnosis of duplicated GB was made based on the histopathology.

INTERVENTIONS

The patient underwent a laparoscopic cholecystectomy with total removal of the duplicated GB.

OUTCOMES

The patient's postoperative course was uneventful and she was discharged from the hospital on the second postoperative day. She had no upper abdominal pain at the 6-month follow-up.

CONCLUSION

Duplicated gallbladder is a rare congenital biliary anatomy, which is usually asymptomatic and sometimes cannot be diagnosed on preoperative imaging. With gallbladder disease, the duplicated GBs should be removed totally; a laparoscopic approach should be attempted first and cholangiography is recommended to aid in identifying and resecting the duplicated GBs. The final diagnosis depends on the histopathology. There is still insufficient evidence on the need to remove duplicated GBs found incidentally.

Outcome of non-visualization of fetal gallbladder on second-trimester ultrasound: cohort study and systematic review of literature

OBJECTIVES

To investigate the ultrasound characteristics and outcome of fetuses with non-visualization of the fetal gallbladder (NVFGB) followed in our tertiary university hospital, and to provide a comprehensive review of the literature on prenatal findings and outcome of NVFGB.

METHODS

NVFGB was defined as non-visualization of the gallbladder on two targeted ultrasound examinations performed within a 1-week period. First, we reviewed the medical records of NVFGB cases managed in our center over a 9-year period. Then, we performed a systematic review of the literature to identify studies on NVFGB. The incidence of chromosomal anomalies, later visualization of the gallbladder, gallbladder agenesis, cystic fibrosis and biliary atresia was assessed in fetuses with isolated and non-isolated NVFGB. The role of hepatic enzyme measurements in the diagnosis of cystic fibrosis and biliary atresia in fetuses with NVFGB was also reviewed.

RESULTS

Sixteen cases of NVFGB were followed in our center, in 10 (62.5%) of which it was an isolated finding. The incidence of biliary atresia was 12.5% and that of gallbladder agenesis was 12.5%, while no case of cystic fibrosis was reported. The gallbladder was visualized later in pregnancy or postnatally in 43.8% and 25.0% of cases, respectively. A total of seven studies, including our cohort, involving a total of 280 NVFGB cases, met the inclusion criteria for the systematic review. Overall, 20.5% of fetuses had an associated ultrasound anomaly, and the incidence of chromosomal anomaly in this group was 20.4%. In cases with isolated NVFGB, the incidence of chromosomal anomaly was 1.9%. In fetuses with normal karyotype and isolated NVFGB, the gallbladder was later visualized in 70.4% of cases, while the incidence of gallbladder agenesis, cystic fibrosis and biliary atresia was 25.2%, 3.1% and 4.8%, respectively. In fetuses with non-isolated NVFGB, the incidence of cystic fibrosis and biliary atresia was 23.1% and 18.2%, respectively. The negative predictive value of amniotic fluid enzyme levels for the prediction of severe disease (including biliary atresia or cystic fibrosis) ranged between 94% and 100% when evaluated before 22 weeks' gestation, and dropped to 88% after 22 weeks.

CONCLUSIONS

In cases with persistent NVFGB, the risk of a severe postnatal condition should be considered. A detailed ultrasound scan should be offered and parents tested for cystic fibrosis gene mutation. An invasive procedure for karyotyping and measurement of liver enzyme concentrations before 22 weeks constitutes a reasonable work-up. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Unusual radiological image: the floating gallbladder

Radiological images of a patient consulting the emergency room for pain in the right hypochondrium and hypercalcified images in the right-medial area of ​​the upper hemiabdomen, which correspond to the floating gallbladder.

A case of an absent gall bladder presenting as biliary colic in a tertiary care hospital in Karachi

Gallbladder agenesis is a rare congenital anomaly occurring in 10-65 per 100,000 populations with the incidence being more common in females with a ratio of 3:1. Although asymptomatic, some patients present with symptoms like biliary colic and often indistinguishable from common conditions leading to unnecessary surgery. A 19-year old woman presented to the hospital with epigastric and right upper quadrant pain, other signs and symptoms consistent with biliary colic. However, on laparoscopy gall bladder was absent. Ultra-sound of the abdomen is the preferred for gallbladder diseases but due to scarcity of reports on gallbladder agenesis, it is often misread due to periportal tissue and sub-phrenic folds often reported as gallbladder or calculi leading to unnecessary surgery. Agenesis, a rare anomaly, poses a diagnostic dilemma to surgeons as it is usually diagnosed during a laparoscopic cholecystectomy. Clinicians should keep in mind this entity when the gallbladder is poorly visualized on ultrasound and think of more detailed investigations such as Magnetic resonance cholangiopancreatography.

Retrohepatic Gallbladder Masquerading as Hydatid Cyst in a Patient with Right Liver Agenesis

Agenesis of the right liver is a rare congenital anomaly which can be associated with an ectopic gallbladder. Hereby, it is presented the case of a 39-year-old man investigated for right upper quadrant abdominal pain and diagnosed at computed tomography with a cystic liver mass initially considered as hydatid cyst. At laparotomy, it was discovered agenesis of the right liver and the presumed hydatid cyst was a retrohepatic gallbladder with lithiasis. Cholecystectomy was performed with an uneventful outcome. Reassessment of the computed tomography images by an experienced radiologist confirmed the intraoperative diagnosis. Although agenesis of the right liver with retrohepatic gallbladder is an exceptional appearance, surgeons should be aware of this anomaly because it can raise challenging issues of diagnosis and surgical planning during cholecystectomy.

Can surgical treatment be justified for neuroendocrine carcinoma of the gallbladder?

Clinical features and treatment of GB neuroendocrine carcinoma (GB-NEC) are not well understood. This study aimed to analyze clinical outcomes of GB-NEC and verify the oncologic benefit of surgical treatment.From October 1994 to December 2014, the medical records of 31 patients with GB-NEC at a single center were retrospectively reviewed. There were 18 inoperable cases due to distant metastasis, including 7 of best supportive care (Tx.1) and 11 of non-operative palliative treatment (Tx.2). 4 patients received non-curative, palliative resection (Tx.3). Only 9 patients were able to undergo curative-intent resection (Tx.4).Among the 31 patients with GB-NEC, preoperative mean value of carbohydrate antigen 19-9 (CA 19-9) was 74.8 ± 156.1 U/mL and the median overall survival time was 10 months (range 7.0-12.0 months). Of these, 21 (67.7%) patients received systemic treatment. Among 9 patients who underwent curative-intent resection (Tx.4), 9 patients had poorly differentiated cancer cells and 7 patients received radical cholecystectomy. 6 patients had adjuvant treatment including concurrent chemoradiation therapy (CCRT) or chemotherapy alone. The recurrence rate was 88.9%. The median overall survival between 4 groups was as follows: 4.0 (3.0-18.0) months in Tx.1 (n = 7) versus 9.0 (3.0-21.0) months in Tx.2 (n = 11) versus 11.0 (3.0-15.0) months in Tx.3 (n = 4) versus 23.0 (8.0-34.0) months in Tx.4 (n = 9), respectively. Significant differences in median overall survival time existed between Tx.2 and Tx.4; 9 (3.0-21.0) months versus 23.0 (8.0-34.0) months (P = .017).Most GB-NECs show poor biologic behavior. Nonetheless, curative-intent resection could possibly promote longer survival than other treatment modalities for GB-NEC. Efforts to undergo curative resection through early detection and development of adjuvant treatment are needed.

A Duplicated Gallbladder in a Patient Presenting with Acute Cholangitis. A Case Study and a Literature Review

Gallbladder duplication can present a clinical challenge primarily due to difficulties with diagnosis and identification. Recognition of this anomaly and its various types is important since it can complicate a gallbladder disease or a simple hepatobiliary surgical procedure. The case report of a 63-year-old woman who presented with cholangitis and underwent a successful laparoscopic management of symptomatic gallbladder duplication is described, emphasizing several important considerations. Using ERCP, MRCP and 3D reconstructions the two cystic ducts with one common bile duct were identified. A review of the literature in referral of this variant, its anatomical classifications and significance to clinical and surgical practice is included. In conclusion, gallbladder anomalies should be anticipated in the presence of a cystic lesion reported around the gallbladder when evaluating radiologic studies. In case of surgery, preoperative diagnosis is essential to prevent possible biliary injuries or reoperation if accessory gallbladder has been overlooked during initial surgery. Laparoscopic cholecystectomy remains feasible for intervention can be safely done and awareness is necessary to avoid complications or multiple procedures.

Surgical challenges of duplicated gallbladder during cholecystectomy

No abstract provided.

Coexistence of double gallbladder with cholangiocarcinoma: A case report

RATIONALE

Gallbladder duplication is a rare congenital disorder, which could cause an increasing risk of complications during surgery. The coexistence of cholangiocarcinoma with double gallbladder is extremely rare, which might lead to an even higher possibility of misdiagnosis and postsurgery complications.

PATIENT CONCERNS

A 58-year-old female was presented with abdominal pain and jaundice. Abdominal ultrasonography showed duplication of gallbladder, one of which with a thickened wall and a rough surface. This was also confirmed by an abdominal computed tomography (CT), magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) scan. During the surgery, we found a tumor inside one bile duct. The postsurgery pathology showed adenosquamous carcinoma.

DIAGNOSES

Gallbladder duplication, cholangiocarcinoma.

INTERVENTIONS

The tumor was removed by surgery.

OUTCOMES

The patient died of tumor relapse six months after surgery.

LESSONS

This is the first reported case with coexistence of gallbladder duplication and cholangiocarcinoma, which was diagnosed by abdominal ultrasound, CT and MRCP, as well as further confirmed in surgery and pathology. This case emphasized the importance of a thorough examination of gallbladder before surgery, especially in those cases with suspected double gallbladder, since each gallbladder could have the possibility of an independent cholangiocarcinoma.

Unsuspected Duplicated Gallbladder in a Patient Presenting with Acute Cholecystitis

Duplicated gallbladder (GB) is a rare congenital disease. Surgical management of a duplicated GB needs special care because of concurrent bile duct anomalies and the risk of injuring adjacent arteries during surgery. An 80-year-old man visited an emergency room with right upper quadrant abdominal pain. Computed tomography (CT) revealed cholecystitis with a 2-bodied GB. Because of this unusual finding, magnetic resonance choledochopancreatography was performed to detect possible biliary anomalies. The 2 GB bodies were unified at the neck with a common cystic duct, a so-called V-shaped duplicated GB. The patient's right posterior hepatic duct joined the common bile duct (CBD) near the cystic duct. The patient underwent laparoscopic cholecystectomy without adjacent organ injury, and was discharged uneventfully. Surgeons should carefully evaluate the patient preoperatively and select adequate surgical procedures in patients with suspected duplicated GB because of the risk of concurrent biliary anomalies.

[Isolated gallbladder agenesis without biliary atresia in a 16-year-old boy]

We present a case of a 16-year-old male patient with recurrent abdominal pain in the upper right quadrant, signed up for elective laparoscopic cholecystectomy due to a single gallstone seen on preoperative abdominal ultrasound. Because of dilatation of the common bile duct subsequent magnetic resonance cholangiopancreatography was performed, and surprisingly, the gallbladder was found missing. The operation was therefore cancelled. Even though gallbladder agenesis is a rare condition, it still represents a diagnostic challenge as most cases are found peroperatively, and the patients undergo unnecessary surgery.

Anomalous radiological and clinical demonstration of gallbladder duplication in an asymptomatic pregnant female

Gallbladder duplication is an uncommon congenital anatomical deviation encompassing a number of variants. The morphological difference occurs during budding of the hepatic diverticulum. We report the case of an asymptomatic pregnant woman who was incidentally found to have a large subhepatic cyst on ultrasound. The case highlights the difficulty in diagnosing large gallbladder duplication and the different radiological imaging available to surgeons to aid in mapping such anatomical variants. We propose that this case holds valuable lessons for both radiologists and surgeons when considering the differential diagnosis and management of large hepatobiliary cysts.

Fetal stomach and gallbladder in contact with the bladder wall is a common ultrasound sign of stomach-down left congenital diaphragmatic hernia

PURPOSE

The aim of this study was to identify sonographic (US) findings that can assist in prenatal diagnosis of stomach-down left congenital diaphragmatic hernia (CDH), specifically related to positioning of the abdominal contents including the stomach, bladder, and gallbladder.

METHODS

All US examinations with a postnatally confirmed diagnosis of stomach-down left CDH over a 13-year period were retrospectively reviewed for abnormal position of the abdominal contents, including whether the fetal stomach was in contact with the urinary bladder. Normal fetuses that underwent comprehensive US surveys were similarly evaluated for comparison in a 2:1 ratio.

RESULTS

Twenty-two fetuses with stomach-down left CDH were identified in a cohort of 278 fetuses with left CDH. In 15/22 (68.2%) cases of stomach-down left CDH, the bladder and stomach walls were in contact. Contact of the fetal gallbladder with the fetal bladder wall was also observed and was present even more commonly (17/22 cases [77.3%]). There was no case of either the stomach or gallbladder in contact with the bladder wall in the normal fetal cohort (n = 44).

CONCLUSIONS

Recognition of the fetal stomach and/or gallbladder in contact with the bladder wall can help in the detection of stomach-down left CDH. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:8-13, 2017.

Accessory gallbladder in an intrahepatic location mimicking a cystic tumor of the liver: A case report

BACKGROUND

Double gallbladder (GB) is a rare congenital anomaly of the biliary system characterized by the presence of an accessory GB.

CLINICAL FINDINGS

A 38-year-old female presented with a history of right upper quadrant (RUQ) pain. Computed tomography (CT) showed a lobulated cystic mass involving the center portion of liver. Magnetic resonance imaging (MRI) additionally revealed a tubular structure of T2 bright signal intensity (SI), which connected the cystic lesion of the liver to the bile duct. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) confirmed the connection between the intrahepatic cystic lesion and the left main hepatic duct. We regarded as a cystic mass with biliary communication, such as a cystic intraductal papillary neoplasm of the bile duct (IPNB) or localized Caroli disease. The patient underwent partial hepatectomy for the cystic mass of the liver and a final diagnosis of chronic inflammation of an intrahepatically located accessory GB was made.

CONCLUSION

We report a case of an accessory GB in an intrahepatic location mimicking a cystic mass such as cystic IPNB or localized Caroli disease of the liver showing a cystic mass with biliary communication.

[Gallbladder agenesis: case report and a literature review]

Gallbladder agenesis is a rare disease, which its symptomatology emulates biliary pathology. It is presented between 0.007 to 0.027% of those patients in whom a cholecystectomy is performed. After it, its evolution is asymptomatic. We present the case of a 19 years old female patient with clinical presentationof cholelithiasis. Ultrasound reveals scleroatrophic vesicle. Elective cholecystectomy was performed,but the gallbladder was not found. The patient presented an asymptomatic evolution in the postoperative period and in the annual follow-up. In addition, we performed a case review from clinical case reports obtained from Medline. Fourteen patients were included in the review of cases, compared to another five studied in a series of cases. There was no significant difference between the two groups. Gallbladder agenesis usually happens between 40 and 64 years, with pain in the upper right quadrant and ultrasound diagnosis of cholelithiasis. It is unlikely to reach a preoperative diagnosis. If it is intervened, it is preferable to limit to laparoscopic examination. The following evolution will be asymptomatic, althoughthe cause of it is not known yet.

Accessory Lobe of Liver Associated with a "Bean Shaped" Gall Bladder

Occurrence of accessory lobes of liver and anomalies of gall bladder is quite common. A thorough knowledge of their variation can minimise diagnostic and surgical errors. We found concurrent variations of liver and gall bladder. A small accessory liver lobe was attached to the quadrate lobe through a stalk formed by peritoneum. The gall bladder was "bean shaped" due to the presence of a constriction in the middle of its body. Since the accessory lobe was quite close to gall bladder, it could compress the gall bladder and hinder normal functioning of it. The knowledge of these variations might be of importance to radiologists and surgeons dealing with the hepatobiliary 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.

[CONGENITAL MALFORMATION: BILIARY ATRESIA]

Congenital anomalies of biliary tract development are frequent causes of lingering course of physiologic jaundice which need timely verification of diagnosis followed by surgical treatment. Clinical observation of biliary atresia in a 10-month-old girl permits to accent pediatricians’ attention to peculiarities of clinical picture, diagnosis and techniques for treatment of this pathology.

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.

Suprahepatic Gallbladder

INTRODUCTION

Suprahepatic gallbladders have been reported in the literature dating back to 1965. However, their etiology and consequences remain unclear.

METHODS

A case of a patient being treated for biliary dyskinesia with an incidental finding of suprahepatic gallbladder is presented along with a literature review on the causes, effects, and management of a suprahepatic gallbladder.

DISCUSSION

Patient underwent a robotic-assisted laparoscopic cholecystectomy without complications and had an uneventful recovery. Vigilance must be used to rule out ectopic gallbladder location in a patient with atypical biliary symptoms.

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.

Laparoscopic management of double gallbladder

Double gall bladder is a rare congenital anomaly and is challenging to the surgeons due to increased risk of post-operative complications. We present a case of double gall bladder that was successfully managed laparoscopically. Preoperative ultrasonography showed one vesicle of the gall bladder had thick wall with multiple calculi while the other had normal thickness without calculus. Both the gallbladders were connected to the common bile duct with a single cystic duct.

[Duplication of the gallbladder and cystic duct as a rare finding during cholecystectomy - a case report]

Congenital anomalies of the gallbladder, the biliary tract and their vasculature are relatively common. They usually represent only anatomical variations that may not manifest clinically, but in some cases they are of fundamental importance for the surgeon as they can cause diagnostic confusion or lead to problems during surgery. Their ignorance may result in many errors, injury during surgery and subsequent serious consequences. Genuine duplication of the gallbladder with the cystic duct and its artery is extremely rare and is therefore still only a subject of case reports. Gallbladder duplication itself is not an indication for surgery. If it contains stones or if inflammation occurs, however, both gallbladders may not be affected equally and if this variety is not recognized, only one of them may be removed and the other one can escape attention. The case report describes the rare case of gallbladder duplication including the cystic duct during elective cholecystectomy in a middle-aged man who was operated on after birth for omphalocele. Preoperative diagnostic examination described malrotation of the intestine and a cystic lesion next to the gallbladder, considered to be rather a liver cyst. Although it was indeed possible to assume various other abnormalities in the anatomical arrangement of the organs with regard to the patients history, the finding of double gallbladder including cystic duct was still surprising.

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.

Accessory liver lobe attached to the wall of the gallbladder: a cadaveric case report

Accessory liver lobe is found incidentally during laparoscopy, laparotomy or autopsy performed for unrelated reasons. The occurrence of accessory liver lobe attached to the gallbladder is reported rarely in the literature. During regular dissection classes, we came across an accessory liver lobe in the wall of the gallbladder in an adult male cadaver. On its left, it was connected to the quadrate lobe by a short fold of peritoneum. On the right, it was attached to the wall of the gallbladder. The fragment was triangular in shape, and was 20 mm in length, 11 mm in width and 6 mm thick. The histology of the fragment revealed the unusual architecture of hepatic tissue with the absence of the classical hexagonal lobule pattern. Cords of hepatocytes surrounding the central vein, with an absence of portal canals, were observed. There were branches of hepatic artery, portal vein and hepatic duct in its peritoneal fold. Smooth muscle fibers were also observed along its attachment on the wall of the gallbladder. Awareness of the incidence of accessory liver lobe in the wall of the gallbladder is of clinical importance during the diagnosis and treatment of gallstones.

[Galbladder contractility in children with functional dyspepsia]

Disturbances of the gallbladder and biliary tract in children, contrary to those in adults, were not included in Ill Rome Criteria of functional disorders of the alimentary tract. The aim of the work was sonographic assessment of gallbladder function in functional dyspepsia in children.

MATERIAL AND METHODS

The study included 45 children, aged 6 to 18 years (28 girls and 17 boys) with functional dyspepsia and 32 healthy children without symptoms form the alimentary tract of the same age, who were regarded as the control group. Diagnosis of functional dyspepsia was made based on Ill Rome Criteria. Anatomy and contractility of the gallbladder were assessed sonographically taking into consideration its volume in fasting state, than 30 and 60 minutes after the test meal. In anatomy assessment the presence of septum, thickness of the wall and the presence of thickened bile were taken into account.

RESULTS

Anatomical anomalies and wall thickness changes were observed statistically significantly more frequently in children with functional dyspepsia. There was no statistical difference in the volume of the gallbladder in fasting state and its contractility after test meal.

CONCLUSIONS

Anatomical anomalies of the gallbladder were more frequent in children with functional dyspepsia in comparison to healthy children, however, there were no statistical differences in its volume in fasting state and contractility after test meal.

[Double gallbladder - a rare congenital variation]

Double gallbladder, a congenital anatomic variation, represents approximately 2% of all congenital anatomic variations of the gastrointestinal tract, its incidence amounting to about 25 in 100 000. It has several types classified according to Boyden's criteria. The diagnostic method of first choice is ultrasonography. When the patient has no health complaints and cholecystolithiasis is present, no special treatment measures are required. The treatment option in symptomatic cholecystolithiasis is laparoscopic cholecystectomy. Only a few cases of double or triple gallbladder, in contrast to the high number of cholecystectomies, have been published in literature. The authors present a case of double gallbladder where the diagnosis was established more than three years after laparoscopic cholecystectomy

Ectopic thyroid in duplicated gall bladder: a rare entity. Case report

Duplication of the gall bladder is a rare anomaly. Ectopic thyroid in a gall bladder is also exceedingly rare with only four cases of ectopic thyroid tissue in the gall bladder reported in English literature. We report the unique case of ectopic thyroid tissue in a duplicated gall bladder in a 51-year-old female with recurrent right upper quadrant pain. Abdominal sonography revealed a duplicated gall bladder with the cystic-solid mass in the septum separating the two gall bladders while subsequent histopathology from the cholecystectomy specimen confirmed ectopic thyroid tissue within the wall of double gall bladder.

Anatomical and congenital anomalies of extra hepatic biliary system encountered during cholecystectomy

Anomalous biliary anatomy is frequently encountered by surgeons during cholecystectomy. Importance of its recognition lies in avoiding serious biliary injuries. This study was carried out to assess the frequency of anatomical and congenital anomalies of extrahepatic biliary system in patients undergoing cholecystectomy. This is an observational study performed in the Department of Surgery, Combined Military Hospital (CMH) Momenshahi, CMH Ghatail and Mymensingh Medical College Hospital for a period of five years from June 2007 to June 2012. Two hundred and fifty diagnosed patients of cholelithiasis undergoing routine cholecystectomy were assessed for anatomical and congenital anomalies of extra hepatic biliary system as well as vascular anomalies. Structures mainly assessed for anomalies were gall bladder, cystic duct, supraduodenal part of Common Bile Duct (CBD), cystic artery and hepatic artery which are routinely handled during cholecystectomy. However, assessment of variations and anomalies, of hepatic ducts, portal vein, retroduodenal and pancreatic parts of CBD were not done due to possibility of iatrogenic injuries. Two hundred and fifty cases of cholelithiasis comprising 216(86.4%) females and 34(13.6%) males with mean age of 39.15 years were included in the study. Clinical presentation includes mainly pain in right hypochondrium (74.8%), pain in right hypochondrium and epigastrium (18.8%) and pain in epigastrium alone (7.6%). Laparoscopic cholecystectomy was done in 157 patients and 93 patients were treated by open procedure including conversion cases. Operative findings revealed variations in 38 cases (15.2%) mainly involving cystic artery (8%), cystic duct (4.4%) and gall bladder (1.6%). Postoperative complications includes bleeding 3.6%, biliary leak from drain 1.6% and CBD injury 0.8% giving rise to 0.8% morbidity, however, no mortality was seen in this series. Anatomical and congenital anomalies of biliary tree, are not common but may be significant during surgery as failure to recognize them leads to iatrogenic injuries and can increase morbidity and mortality.

Isolated congenital agenesis of the gallbladder and cystic duct: report of a case

Congenital agenesis of the gallbladder and cystic duct represents a rare anomaly of the biliary system. It likely results from an embryologic mishap in the development of the hepatobiliary bud and can occur with other associated malformations. We report the case of congenital absence of the gallbladder and cystic duct incidentally found during laparoscopy in a 44-year-old Caucasian female. Based on the clinical presentation and ultrasonography findings, the patient was presumed to have symptomatic cholelithiasis and chronic cholecystitis. A laparoscopic cholecystectomy was planned. After introducing the laparoscope, the gallbladder and cystic duct were absent and the procedure aborted. Gallbladder and cystic duct agenesis was confirmed by magnetic resonance cholangiopancreatography. We describe here the difficulties with diagnosis and pain management, and review the literature of this rare pathology.

Imaging findings of gallbladder duplication due to two cases: case report and review of literature

Duplication of the gallbladder, a rare congenital anomaly, is important in clinical practice as it may cause some clinical, surgical, and diagnostic problems. This anomaly is also important for surgeons due to the increased risk of complications especially after laparoscopic cholecystectomy. We report ultrasonography, computed tomography, and magnetic resonance cholangiopancreatography findings in two cases of a symptomatic duplicated gallbladder.

Double trouble--duplication of the gallbladder requiring repeat laparoscopic cholecystectomy

Duplication of the gallbladder is a surprisingly common phenomenon. Clinically, these patients present with straightforward gallbladder pathologies. It is a challenging preoperative diagnosis on ultrasound, and most cases are diagnosed intra-operatively. We present a case of gallbladder duplication, where the patient presented with biliary colic, had a straightforward laparoscopic cholecystectomy, and then represented with biliary colic four years later.

Congenital duplex gallbladder anomaly presenting as gangrenous perforated intrahepatic cholecystitis mimicking a gas forming liver abscess: A case report and literature review

BACKGROUND

Ectopic intrahepatic gallbladder is a rare phenomenon. Gallbladder duplication is an even rarer phenomenon. Pathological processes are more common in congenital anomalies of the gall bladder than normal gallbladders due to poor drainage.

CASE REPORT

We present a case of duplex gallbladder with one component intrahepatic and the other extra-hepatic, the duo draining via a common cystic duct into the common bile duct. Both gallbladder moieties were diseased. The intrahepatic moiety was gangrenous and perforated thus mimicking an intrahepatic abscess by a gas forming organism. The extra-hepatic moiety was chronically inflamed and packed with gallstones of the same physical and biochemical characteristics as the intrahepatic moiety. The definitive diagnosis was only made at emergency laparotomy. Stone gathering and debridement of the ruptured, gangrenous intrahepatic moiety and cholecystectomy for the extra-hepatic moiety was done. On table cholangiography, though desired, was not available. The patient fully recovered after post-operative intensive care.

CONCLUSION

An extensive internet literature search did not reveal any previously described case. This could be the first such case described in the world literature. Though rare, congenital anomalies of the gallbladder must be known to surgeons as they can present unexpectedly and pose diagnostic and operative surgical challenges with serious clinical implications. The management challenges experienced and literature review is presented.