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 ¤  Abstract
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UNUSUAL CASE
Year : 2008  |  Volume : 4  |  Issue : 1  |  Page : 20-22
 

Septate gallbladder in the laparoscopic era


Department of Gastrointestinal and Laparoscopic Surgery, Sterling Hospital, Sterling Hospital Road, Memnagar, Ahmedabad, Gujarat, India

Correspondence Address:
Nitin R Patel
Department of Gastrointestinal and Laparoscopic Surgery, Sterling Hospital, Sterling Hospital Road, Memnagar, Ahmedabad - 380 052, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9941.40994

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 ¤ Abstract 

The anatomy facing a surgeon during cholecystectomy is challenging as it involves complex relationship between the gallbladder, hepatic artery and extra-hepatic billiary tree. We report a case of septate gall bladder which was successfully treated with laparoscopic cholecystectomy. In this paper, we also discuss the embryology and characteristics of this rare anomaly. Lack of awareness, non-specific symptoms, signs and inadequacy of imaging methods are possible reasons for the reported problem of overlooking of this entity. Complete identification and removal of gallbladder is mandatory, as a remnant may result in recurrence of symptoms or stones.


Keywords: Gallbladder anomalies, laparoscopic treatment, septate gallbladder


How to cite this article:
Patel NR, Joshipura VP, Haribhakti SP, Soni HN. Septate gallbladder in the laparoscopic era. J Min Access Surg 2008;4:20-2

How to cite this URL:
Patel NR, Joshipura VP, Haribhakti SP, Soni HN. Septate gallbladder in the laparoscopic era. J Min Access Surg [serial online] 2008 [cited 2020 Sep 21];4:20-2. Available from: http://www.journalofmas.com/text.asp?2008/4/1/20/40994



 ¤ Introduction Top


Congenital anomalies of the gallbladder are rare and wide range of malformations pertaining to all aspects have been described. [1] Septate gallbladder has not been well documented because it is usually asymptomatic or discovered accidentally during the evaluation of abdominal pain. [1] Rarely due to septation there may be stone formation, which might lead to recurrent abdominal pain. [2] We report a case of septate gallbladder that underwent successful laparoscopic cholecystectomy (LC). This case illustrates the need for complete removal of gallbladder during surgery. Precise intraoperative recognition of vascular and billiary anatomy is necessary to avoid common bile duct (CBD) injuries and gallbladder remnants.


 ¤ Case Report Top


A 55-year-old male patient was admitted to our hospital with a right upper quadrant pain recurring for the past 10 years. There was a history of postprandial fullness, belching and sour eructation's. There was no history of jaundice in past. His blood values were within normal range. Ultrasound (US) of upper abdomen showed the gallbladder with a Phrygian cap filled with multiple calculi. LC was planned.

At laparoscopy, flimsy adhesions were identified at the fundus of the gallbladder. After retracting the fundus towards the ipsilateral shoulder dense adhesions were present at the body of the gallbladder. After completing adhesinolysis with blunt and sharp dissection we found a septated structure [Figure 1]. Calot's triangle was dissected. Cystic artery and Cystic duct were clipped and divided. LC was successfully completed without any complication [Figure 2]. No drain was used in the patient. The duration of the operation was 40 min. The postoperative period was uneventful and the patient was discharged on the second postoperative day. On follow-up appointments, patient was in good condition.

Gross examination of the specimen [Figure 3] showed a horizontal septum with a pinhole communication. The cephalic moiety showed two stones and distal moiety was thin-walled and completely empty. There was evidence of acute inflammatory changes over entire wall.


 ¤ Discussion Top


Anomalies of the gallbladder have been classified into malformation of shape, number, site, size and heteropias. These anomalies may be asymptomatic or may cause wide range of complications.

Septate gallbladder is characterized by the presence of a septum that divides the gallbladder in two chambers. When the septum dividing the gallbladder lies longitudinally it is called bilobed gallbladder and when there is a transverse septum separating the fundus from the rest of the gallbladder it is called an hour-glass gallbladder. [2] Septate gallbladders most likely result from incomplete resolution of the solid stage of gallbladder development that is present before the third month of fetal development. These gallbladder septae are most commonly single, but multi septate gallbladder, as well as post inflammatory adhesions and compartmentalization of the gallbladder have also been described. [3]

In our patient the septa were most probably congenital in origin with superadded inflammation which gave rise to classic septate shaped gallbladder. Secondly bile stasis and infection in the fundic part would have led to the development of the gallstones in this patient.

According the Boyden classification, [4] these congenital anomalies of gallbladder are classified according to the ductal formation as bilobed (or bifid), "V-shaped" and "H-shaped" (or ductular) gallbladder types. Classification of different types of double gallbladders is shown in [Table 1]. [5] The gallbladder in our case was compatible with the V-shaped one. To date US oral cholecystography oral cholecysto-computed tomography, scintigraphy, magnetic resonance cholangiography, percutaneous transhepatic cholangiography and endoscopic retrograde cholangiopancreatography have been used preoperatively to diagnose these anomalies. [6]

Consequently, identification and definition of biliary anatomy is mandatory to prevent biliary system injury. Injury to the ductal system usually occurs during dissection of Calot's triangle. All connective tissue and fat must be removed completely to clearly expose the junction of the cystic duct with the gallbladder. We also performed meticulous dissection, keeping in mind principles of LC to prevent inadvertent injury. A careful appraisal of reported literature clearly emphasizes the need for removal of complete gallbladder to prevent surgical complications and repeated explorations. The author has treated two cases of stone in remnant of the gallbladder, after laparoscopic cholecystectomy.

In conclusion, this case illustrates the need for complete removal of gallbladder, as a remnant could be a good seat for development of stone in future and subsequent recurrence of symptoms.

 
 ¤ References Top

1.Gross RE. Congenital anomalies of the gall bladder: A review of 148 cases, with report of double gall bladder. Arch Surg 1936;32:131-62.  Back to cited text no. 1    
2.Flannery MG, Caster MP. Congenital hour-glass gall bladder. South Med J 1957;50:1255-8.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Adear H, Barki Y. Multi septate gall bladder in a child: Incidental diagnosis on sonography. Paediatr Radiol 1990;20:192.  Back to cited text no. 3    
4.Gigot J, Van Beers B, Goncette L. Laparoscopic treatment of gallbladder duplication: A plea for removal of both gallbladders. Surg Endosc 1997;11:479-82.  Back to cited text no. 4    
5.Silvis R, van Wieringen AJ, van der Werken CH. Reoperation for a symptomatic double gallbladder. Surg Endosc 1996;10:336-7.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Oyar O, Yesildag A, Gulsoy U, Sengul N, Isler M. Bilobed gallbladder diagnosed by oral cholecysto-CT. Comput Med Imaging Graph 2003;27:315-9.  Back to cited text no. 6    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]

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Nuclear Medicine and Molecular Imaging. 2013; 47(3): 220
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2 Multiseptate gallbladder. An unusual congenital anomaly [Vesícula biliar multiseptada. Una anomalía congénita infrecuente]
Nelson Menocal, F. and Aurora Garrote, P. and Diana García, C. and José Miguel Alonso, S. and José Angel Santos, S.
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[Pubmed]
3 Bilobed gallbladder
Alam, M.T. and Qaiser, B. and Jamaluddin, M. and Hussain, S.M.A.
Journal of the College of Physicians and Surgeons Pakistan. 2011; 21(6): 367-368
[Pubmed]



 

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