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 ¤ Introduction
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 Table of Contents     
UNUSUAL CASE
Year : 2018  |  Volume : 14  |  Issue : 4  |  Page : 335-337
 

Laparoscopic management of a case of accessory gall bladder with review of literature


1 Department of Laparoscopic and General Surgery, Max Super Specialty Hospital Dehradun, Uttarakhand, India
2 Department of Gastro-Enterology, Max Super Specialty Hospital Dehradun, Uttarakhand, India
3 Department of Pathology and Microbiology, Max Super Specialty Hospital Dehradun, Uttarakhand, India
4 Department of Pathology and Microbiology, Max Super Specialty Hospital Saket, New Delhi, India

Date of Submission11-Dec-2017
Date of Acceptance07-Feb-2018
Date of Web Publication3-Sep-2018

Correspondence Address:
Dr. Guru Prasad Painuly
Department of Laparoscopic and General Surgery, Max Super Specialty Hospital, Malsi, Mussoorie Diversion Road, Dehradun - 248 003, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_248_17

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 ¤ Abstract 

Gall bladder duplication is a rare congenital anomaly. True duplication is still rarer. Pre-operative detection helps in avoiding complications or missing the gall bladder during surgery. Ultrasonography (USG) and magnetic resonance cholangiography are investigation of choice. Laparoscopic cholecystectomy is the preferred modality for management of double gall bladder. We present a case diagnosed as cholelithiasis on USG. While doing laparoscopic surgery 2 gall bladders were found. She had a normal gall bladder that was lying in the supraduodenal area. It had cystic duct that joined the common bile duct. There was an accessory gall bladder attached to the anterior free margin of the liver. This gallbladder was occluded with a big solitary calculus occupying the whole of gall bladder cavity and had a small feeding vessel; whereas its duct had fibrosed.


Keywords: Duplication of gall bladder, extra gall bladder primordium, laparoscopic cholecystectomy, magnetic resonance cholangiography


How to cite this article:
Painuly GP, Gupta A, Singhal M, Bansal B. Laparoscopic management of a case of accessory gall bladder with review of literature. J Min Access Surg 2018;14:335-7

How to cite this URL:
Painuly GP, Gupta A, Singhal M, Bansal B. Laparoscopic management of a case of accessory gall bladder with review of literature. J Min Access Surg [serial online] 2018 [cited 2020 Feb 21];14:335-7. Available from: http://www.journalofmas.com/text.asp?2018/14/4/335/231910



 ¤ Introduction Top


Duplication of gall bladder is a rarity, incidence being 1:4000 of the autopsies.[1] Occurs due to division of gall bladder primordium in the 5th–6th embryonic week. A true double/accessory gall bladder develops due to the formation of an extra gall bladder primordium.[1] In case of true duplication, both gall bladder may have a common or different cystic duct and also blood supply. Differential diagnosis of gall bladder duplication includes Phrygian cap deformity, gall bladder diverticulum, choledochal cyst, focal adenomyomatosis, folded gall bladder, pericholecystic fluid and intraperitoneal fibrous band. Preoperative diagnosis helps in preventing any complications during laparoscopic cholecystectomy.[2]


 ¤ Case Report Top


A 61-year-old female having recurrent attacks of pain (grade 7/10) admitted to emergency. Abdominal examination revealed tenderness in epigastrium and right hypochondrium. A diagnosis of recurrent acute cholecystitis cause cholelithiasis was made based on ultrasonography (USG) and patient prepared for surgery. Nothing remarkable was noted in other investigations. Magnetic resonance (MR) and cholangiography/endoscopic retrograde cholangiopancreatography were not done. In routine cases of cholelithiasis our policy is to go by USG alone if no pathology in biliary duct system is suspected.

After insertion of ports, one gall bladder like structure was found hanging from the free edge of liver [Figure 1]; its thin pedicle entered the liver substance. Pedicle consisted of a thin artery and a fibrous band. The portal and supraduodenal area were explored. Gall bladder, cystic duct and Calot's Triangle were defined, and cystic duct followed by cystic artery was clipped and gall bladder extracted out. It contained solitary calculus.
Figure 1: The four main types of gall bladder duplication. Top left: Double gall bladder with a Y-shaped cystic duct entering the common bile duct. Top right: Double gall bladder with independent cystic duct entering the common bile duct. Bottom left: The second gall bladder is connected by its own cystic duct in the left hepatic duct. Bottom right: The cystic duct of the duplicated gall bladder enters the right lobe of the liver to connect with the right hepatic duct (Classification of accessory gall bladder by Philippe Jeanty)

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The pedicle of accessory gall bladder was ligated, and it was extracted out. It has a big solitary calculus. Both the gall bladders were labelled and sent for histopathology examination [Figure 2].
Figure 2: Case photograph. Accessory gall bladder is seen hanging from the free edge of liver; normal gall bladder at 8 - 9 ‘O’ clock position.

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 ¤ Discussion Top


Boyden[1] was first to classify gall bladder duplication in 1926 into 2 broad groups:

  • Vesical fellea divisa or bilobed gall bladder – this has one cystic duct.
  • Vesical fellea duplex – here the two gall bladders have 2 cystic ducts; it is further divided into 2 types. Y type where both cystic ducts fuse and then join the common bile duct. In the H type, both cystic ducts join the common bile duct separately.


Another classification was given by Gross RE, who divided duplication of gall bladder into 6 subtypes. Harlaftis et al.[2] divided gall bladder duplication into 2 main groups:

  • Type 1 split primordial gall bladders classified as septate, V type and Y type
  • Type 2 Accessory gall bladders divided as H type, ductular and trabecular type.


Jeanty and Sutter[3] have divided gall bladder duplication into 4 main types:

  1. Double gall bladder with a Y-shaped cystic duct entering the common bile duct
  2. Double gall bladder with independent cystic duct entering the common bile duct
  3. The second gall bladder is connected by its own cystic duct in the left hepatic duct
  4. The cystic duct of the duplicated gall bladder enters the right lobe of the liver to connect with the right hepatic duct.


[Figure 1](illustration) with permission from ‘the fetus. net’.

Our case falls into type 4 of the classification given by Philippe Jeanty and also H type ductular in Harlaftis and Vesica fellea duplex H-shaped as per Boyden's classification. The accessory gall bladder occurs adjacent to normal gall bladder in the gall bladder fossa, intrahepatic, subhepatic or with in the gastrohepatic ligament. In our case, gall bladder was hanging freely from the margin of segment V of the liver.

USG and MR cholangiography remain the most used diagnostic methods; none of the modalities are 100% sensitive. It is often found incidentally during surgery for cholelithiasis.[4]

In the English literature, more than 200 cases of duplication of gall bladder have been reported. The author could find a total of 30 cases of gallbladder duplication published that were managed laparoscopically. First time cholecystectomy for double gall bladder was done by James Sherren. Mir Yasir et al., Sadf Ali et al. have reported cases of duplication of gall bladder that were diagnosed during laparoscopic cholecystectomy. Vijayraghavan and Belagavi.[5] Reported a case of true accessory/actual duplication of gall bladder where the cystic duct had obliterated and had no communication with biliary tree. Various other authors have published cases of gall bladder duplication that were managed laparoscopically.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ¤ References Top

1.
Boyden EA. The accessory gall bladder-an embryological and comparative study of biliary vesicles occurring in man and domestic mammals. Am J Anat 1926;38:177-231.  Back to cited text no. 1
    
2.
Harlaftis N, Gray SW, Skandalakis JE. Multiple gall bladders. Surg Gynecol Obstet 1977;145:928-34.  Back to cited text no. 2
    
3.
William B. Sutter, MD*, Philippe Jeanty, MD, PhD. The fetus net. 1991-04-06 08. Gallbladder, duplication © Sutter www.thefetus.net/. Gallbladder, duplication. https://sonoworld.com/fetus/page.aspx?id=231.  Back to cited text no. 3
    
4.
Miyajima N, Yamakawa T, Varma A, Uno K, Ohtaki S, Kano N, et al. Experience with laparoscopic double gallbladder removal. Surg Endosc 1995;9:63-6.  Back to cited text no. 4
    
5.
Vijayraghavan R, Belagavi C. Double gall bladder with different disease entities: A case report. J Minim Access Surg 2006;2:23-6.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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