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CASE REPORT
Year : 2022 | Volume
: 55
| Issue : 5 | Page : 190-192
Left or right is right? Ectopic gallbladder
Jithin T Chand, George G Tharakan, George M Sebastian
Department of Surgical Gastroenterology and Gastrointestinal and Hepatopancreatobiliary Oncosurgery, Amala Institute of Medical Sciences, Thrissur, Kerala, India
Correspondence Address:
Jithin T Chand
Sauparnika, Nedumkunnam P.O, Kottayam - 686 542, Kerala
India
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/fjs.fjs_67_22
Ectopic gallbladder (GB) is a rare entity with an incidence of <1%. True left-sided GB (LSG), i.e., GB seen under the left lobe of the liver and to the left of the falciform ligament, presents as a surgical problem on table, due to its unusual presentation and lack of findings on imaging. What we may perceive as an LSG on the table, may in fact be a normally located GB under the right lobe but with the ligamentum teres being attached to the right lobe, giving the appearance of a left-sided gallbladder. Here, we are presenting a case of a true LSG which was discovered on table. By minimizing the use of electrocautery and placing an additional port along with the traditional ports in laparoscopic cholecystectomy, we were able to perform a successful cholecystectomy.
Keywords: Cholecystectomy, ectopic gallbladder, falciform ligament, left-sided gallbladder, situs inversus
Laparoscopic cholecystectomy (LC) is a common procedure in surgical practice. However, encountering a left-sided gallbladder (LSG) is a rare occurrence. The gallbladder (GB) is usually located on the undersurface of the right lobe of the liver along with segments V and IV b. GB located anywhere else is termed as ectopic GB. There are reports of LSG in the literature to the tune of 0.04%–1.1%.[1]
Case HistoryOur patient is a 54-year-old woman, who presented to us with complaints of a vague upper abdominal discomfort and pain over the right infrascapular region for 1 month. There was no history of jaundice or fever with chills. On evaluation with an abdominal ultrasonography (USG), she was diagnosed to have cholelithiasis [Figure 1]. As she was symptomatic, she was advised to undergo LC. We do not routinely perform magnetic resonance cholangiopancreaticography at our institution, unless there is an unusual finding in abdominal USG. Pneumoperitoneum was created through open Hasson's technique. Initially, the GB was not seen in its usual position [Figure 2]. On retracting the falciform ligament (FL), the GB was seen to be intrahepatic to segment III [Figure 3]. To facilitate an easy dissection, an additional 10-mm working port was placed in the left hypochondrium along the midclavicular line. Retracting the fundus of GB cranially, the cystic duct could be seen entering the common hepatic duct (CHD) on the right side [Figure 4]. We proceeded with retrograde cholecystectomy. We tried to minimize electrocautery use toward the Calot's triangle, to prevent any inadvertent injury to the common bile duct (CBD). Calot's anatomy was normal, and the cystic duct and artery were clipped and ligated. The patient tolerated the procedure well, and she was discharged on the same evening. The histopathology was reported as chronic calculous cholecystitis.
Figure 1: Ultrasonography abdomen showing gallbladder with multiple calculi, the largest measuring 1.2 cm
Figure 2: Initial laparoscopic view showing the GB to not be in its usual location. RL: Right lobe liver, FL: Falciform ligament GB: Gallbladder
Figure 3: On retracting the falciform ligament, gallbladder seen intrahepatic to Segment III of Liver. GB: Gallbladder, FL: Falciform ligament
Figure 4: Fundal traction showing the anatomy. Cystic duct opening into the right side of CHD. CHD: Common hepatic duct, GB: Gallbladder, CD: Cystic duct, CBD: Common bile duct, D: Duodenum Discussion GB is usually located on the undersurface of segments V and IVb along the von Rex-Cantlie line, the vertical plane running from GB bed anteriorly to inferior vena cava posteriorly.[1],[2] Ectopic GB is a rare entity with an incidence of <1%.[3] There are four described types of ectopic GB according to gross (1) intrahepatic GB (most common), (2) left-sided GB, (3) transverse position of GB, and (4) retrodisplaced GB (least common).[1],[2],[3] These may be found in the lesser omentum, retroduodenal area, FL, and also within the anterior abdominal musculature.[4],[5]
The LSG is further classified as given in [Table 1].[1],[2],[6],[7]
During embryonic development, the hepatic diverticulum cranially forms the liver and GB. Caudally, a part of the bile duct forms GB and cystic duct.[3],[8] One theory states that the developing GB is attached to the left lobe and hence carried over to the left side of the FL. Another theory states that an accessory left GB develops from the left hepatic duct followed by regression of the primary GB.[1],[2] There is evidence in current literature stating the failure of development of the quadrate lobe also leads to an LSG.[1]
LSG presents with pain in the right hypochondrium as there may not be any variation in the site of pain as the visceral pain fibers do not transpose on the GB as it migrates to the left side.[6] In our case, the patient developed pain over the right shoulder and there was no history of abdominal pain.
LSG may be diagnosed on USG as a floating mass under the left lobe of the liver. This can further be confirmed with a hepatobiliary iminodiacetic acid scan. Intraoperative cholangiography (IOC), in the event that a GB is not seen in its usual location, will also confirm the presence of the GB and the insertion of the cystic duct into the CHD.[9],[10]
Some LSGs are incorrectly diagnosed as they appear to be on the left side of the FL, but in reality, it is the FL which is not attached in the normal location. These need to be termed as R-LSG and is usually associated with variations in the portal and biliary radical anatomy, with the most common being trifurcation of the portal vein.[8] An awareness of these anomalies is required to facilitate safe surgery even though the latter is of less importance during a LC.
LSG creates diagnostic confusion for the surgeon partly due to unusual presentation and due to negative findings on USG and abdominal computed tomography. A careful delineation of the anatomy, preferably without electrocautery dissection, is necessary to avoid injury to CBD and CHD. Placing a new port, as was done in our case, may help in performing the surgery [Figure 5]. If found incidentally, it is advised to remove the ectopic GB due to the abovementioned reasons.[9]
Figure 5: Port placements for surgery. X: 10 mm ports,-: 5 mm ports, black shows traditional port placements and red shows new port placement Conclusion The knowledge of ectopic GB with its varied presentation and lack of positive findings on imaging helps the surgeon in performing a safe cholecystectomy. IOC aids in the understanding of anatomy. Minimizing electrocautery dissection may prevent inadvertent injury to the bile duct. A different port placement as compared to traditional LC may provide better ergonomics when performing surgery.
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 identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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