A patient in his 60s presented with acute and persistent epigastric pain. Accompanied by nausea and vomiting. The patient medical history revealed a pre-existing, neglected, case of hepatitis C virus (HCV) infection Which had progressed to hepatocellular carcinoma (HCC) over time. Furthermore, the patient exhibited liver cirrhosis, with compensated hepatic cell failure, which was compounded by the presence of mild ascites. Associated with malignant thrombus present in the IVC extending to the right atrium and another thrombus of the portal vein.

physical examination showed guarding upon palpation of the epigastrium, mass in the same region, and positive Murphy sign. accompanied by a low-grade fever (37.9 C) Notably, the presence of caput medusa on the abdominal region was also recognized indicating extensive portocaval anastomosis.

Laboratory investigations were conducted, and their findings were elevated leucocyte count ( 14*103/UL), normal liver functions WBC’s 14*103/UL (serum direct billirubin:0.37 mg/dl, T. Bilirubin: 0.8 mg/dl), Normal kidney function (Blood urea nitrogen (BUN)) = 72 U/l, Elevated C-reactive protein (CRP) = 65, Gamma-Glutamyl Transpeptidase (GGT) = 233 mg/dl, Alkaline Phosphatase (ALP) = 167 mg/dl, serving as a crucial reference for the diagnostic process. The patient was admitted to the surgical ward for monitoring and further investigations. Intravenous administration of antibiotics, coupled with the provision of supportive fluids and medications, was promptly initiated. An abdominal computed tomography (CT) scan and laboratory investigation was conducted. After 48 h, comprehensive laboratory were done which revealed that WBCs:18.1*103UL Serum direct bilirubin:0.76 mg/dl, Total bilirubin:1.82 mg/dl, BUN:49U/l, CRP:50,GGT:191 mg/dl, ALP:217 mg/dl. highlighting a concerning decline in the patients overall clinical status.

The computed tomography (CT) Cuts delineated an anatomical positioning of the gallbladder, indicative of a true left-sided configuration

The computed tomography (CT) report delineated an anatomical positioning of the gallbladder, indicative of a true left-sided configuration, concomitant with indications suggestive of acute cholecystitis (Fig. 1).

The Criticality of the patient condition, his rapidly declining clinical status, and the failure of conventional supportive interventions were all factors that led the attending surgeon to speed up the surgery to be done within 48 h of admission. Also due to the unique anatomical constraints, a paramount consideration was taken to avoid compromise of the distended caput medusae. the surgeon modified the positioning of the laparoscopic port incisions to enhance accessibility to the targeted organ (Fig. 2).

Shows modified ports positions to accommodate patient special anomaly

During visualization, signs of acute inflammation were noted, along with omental adhesion requiring dissection and ascites aspiration. Upon gallbladder descent, Calots triangle was incorrectly positioned, with the cystic artery amid the cystic duct and common bile duct (Fig. 3). This matched the CT report and diagnosis of sinsitropositioned gallbladder. After gallbladder extraction, an unusual mass was felt within its wall, where sample dissection revealed adenomyomatosis that was confirmed by the pathologist. Postoperatively there was no complications.

Calots triangle was incorrectly positioned, with the cystic artery amid the cystic duct and common bile duct

The patient was discharged from the hospital after an observation period of three days, with subsequent scheduled appointments planned for comprehensive follow-up evaluation after one week. On follow up visit, patient showed good general condition with improved blood work up. Suddenly, patient admitted to the hospital ICU due deterioration in liver function due to causes that are not related to the procedure.