IMAGES IN LAPAROSCOPY
|Year : 2020 | Volume
| Issue : 4 | Page : 447-448
Laparoscopic treatment of duplicate gallbladder with acute cholecystitis
Rahul A Gupta1, Pradip Pokharia2, Archana Khanduri1
1 Department of Gastrointestinal Sciences, Synergy Institute of Medical Sciences, Dehradun, Uttarakhand, India
2 Department of Radiology, Synergy Institute of Medical Sciences, Dehradun, Uttarakhand, India
|Date of Submission||20-Sep-2019|
|Date of Decision||04-Nov-2019|
|Date of Acceptance||25-Nov-2019|
|Date of Web Publication||09-Jan-2020|
Dr. Rahul A Gupta
Department of Gastrointestinal Surgery, Synergy Institute of Medical Sciences, Dehradun - 248 001, Uttarakhand
Source of Support: None, Conflict of Interest: None
Duplication of gallbladder is a rare congenital anomaly of the extrahepatic biliary tract. Patients with duplicate gallbladder who develop symptoms due to gallstones require surgery. Laparoscopic cholecystectomy in such cases is challenging due to altered biliary anatomy. We report a case of duplicate gallbladder with acute calculus cholecystitis successfully treated by laparoscopic removal of both the gallbladders.
Keywords: Acute cholecystitis, cholecystectomy, gallbladder duplication, gallstones
|How to cite this article:|
Gupta RA, Pokharia P, Khanduri A. Laparoscopic treatment of duplicate gallbladder with acute cholecystitis. J Min Access Surg 2020;16:447-8
A 70-year-old woman presented with the chief complaints of right hypochondriac pain, fever and vomiting for 4 days. Clinical examination revealed right hypochondriac tenderness. Blood investigations were within normal limits. Ultrasonography reported a distended gallbladder with two distinct sacs, suspicious of a bilobed gallbladder containing multiple calculi with wall thickness of 4.2–7.3 mm, suggestive of acute cholecystitis. Computed tomography confirmed the presence of a bilobed gallbladder with multiple calculi and acute cholecystitis [Figure 1].
|Figure 1: Contrast-enhanced computed tomography with three-dimensional reconstruction showing a bilobed gallbladder with thickened walls and radiopaque stone at the infundibulum|
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Intraoperatively, both the gallbladders were densely adhered to each other and could not be identified separately. After dissection of the Calot's triangle, a single cystic duct and cystic artery could be identified [Figure 2]. Both the structures were separately clipped with Hem-o-lok, and cholecystectomy was completed. The operative time was 90 min and the estimated blood loss was 50 ml. On opening the specimen, the bilobed gallbladder separated by septum was confirmed, and a common infundibulum containing calculi could be appreciated [Figure 2]. The postoperative recovery was uneventful. Histopathological examination revealed duplication of all the layers of the gallbladder consistent with duplex gallbladder and florid transmural mixed inflammatory infiltrates, suggestive of acute-on chronic cholecystitis.
|Figure 2: Intraoperative images showing thickened, distended gallbladder with single cystic duct (arrow). Due to the wall thickening and inflammation, it appeared as a single gallbladder. Only after opening the specimen, the presence of duplicate gallbladder with a thick septum and a single neck was confirmed (inset)|
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Laparoscopic cholecystectomy is one of the most common abdominal surgical procedures performed worldwide. The common factors associated with difficult laparoscopic cholecystectomy include male gender, presence of acute cholecystitis, history of endoscopic retrograde cholangiography, acute pancreatitis and Mirizzi syndrome. However, the presence of congenital anomaly of gallbladder, cystic duct or bile duct is also an uncommon risk factor for difficult laparoscopic cholecystectomy.
Duplex gallbladder is a rare congenital anomaly seen in about 1/4000 births. It is broadly classified as vesica fellea divisa (double gallbladder with a common neck), similar to that of the present case, and vesica fellea duplex (two gallbladders with separate cystic ducts). The cystic ducts in vesica fellea duplex can have either Y-shaped or H-shaped configuration. Abdominal ultrasound can raise the suspicion of double gallbladder in most cases. However, there are increased chances of hepatic arterial and bile duct anomalies in such patients, predisposing them to iatrogenic injuries during surgery. Hence, detailed preoperative imaging studies including computed tomography and magnetic resonance cholangiopancreatography should be performed if diagnosed preoperatively.
Surgery is indicated only for symptomatic cases. At surgery, both the gallbladders should be removed even if symptoms are due to one of them. Laparoscopic cholecystectomy can be performed in most cases, like in our case. Slow and meticulous dissection should be performed to delineate the exact anatomy with low threshold for conversion to open surgery. Intraoperative cholangiogram may be performed if altered biliary anatomy is suspected.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published, and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]