Cholecystectomy is one of the most performed surgical procedures worldwide. It comprises the removal of the gallbladder for various indications such as symptomatic gallstones, cholecystitis, gallstone pancreatitis or malignancies of the gallbladder. Since the first performance by Mühe in 1985, laparoscopic cholecystectomy (LC) has become the standard procedure with only a small percentage of conversion (1). LC has minor and acceptable postoperative morbidity and mortality, provided that the patient has a normal anatomy.
The gallbladder lies in the gallbladder fossa beneath hepatic segments IVb and V (2). During the 4th gestational week of the embryological development the biliary system starts to develop from the duodenum by forming a hepatic diverticulum, from this hepatic diverticulum the hepatic part will form the liver and the cystic part the biliary tree (3). Multiple congenital variations of normal anatomy of the gallbladder are known, such as agenesis, duplication, multiseptate, ectopic, and wandering gallbladder (4). In addition, variations in locations have been described as the gallbladder can be found intrahepatic, with transverse or retroverse displacement, or left-sided (5). Left-sided gallbladders (LSG), or sinistroposition, are a group of congenital anomalies that were described for the first time by Hochstetter in 1856 (6). LSG consists of three types; LSG intrinsic to situs viscerum inversus (S-LSG), LSG with an abnormally right-located falciform ligament (R-LSG), or true LSG (T-LSG) (7). A T-LSG is located left from a normally positioned ligamentum teres hepatis (LTH) underneath the left hepatic lobe with the cystic artery crossing the common bile duct (CBD) from right to left. Sinistroposition has a prevalence of 0.1–1.1%, yet T-LSG is even more infrequent with a prevalence of 0.04–0.30% (8).
We report a case of a patient with a T-LSG that underwent LC for symptomatic gallstones at the Zuyderland Medical Center in The Netherlands.
Patient and pre-operative work-up
A 52-year-old female was seen at the outpatient clinic with colicky pain localized in the right upper quadrant of the abdomen, specifically arising after the ingestion of fatty meals. The colicky pain radiated to the back and had been present for two months before the consultation, without symptoms of obstruction, such as jaundice, colored urine, or pruritus. The patient did not smoke, did not take any medication, was allergic to succinylcholine, and had a non-contributing medical history. Besides her obesity, no aberrant findings were found with the physical examination.
The pre-operative work-up for symptomatic gallstones included abdominal ultrasonography and routine laboratory tests. The abdominal ultrasonography showed a thin-walled gallbladder containing multiple gallstones and the liver parenchyma had a diffusely increased echogenicity indicating steatosis hepatis. The abdominal ultrasonography was further reported as normal with slender intra- and extrahepatic bile ducts. Moreover, the routine laboratory tests showed mildly increased alkaline phosphatase, serum transaminases, gamma-glutamyl transferase, and cholesterol.
Routine laboratory tests and electrocardiography (ECG) were performed in the context of pre-operative preparation.
Equipment preference card
Materials used for laparoscopy were Olympus Visera Elite OTV-S190 and Olympus Visera Elite CLV-S190. The camera that was used was the Olympus Endoeye 10 mm 30 degree.
A routine LC was performed. The T-LSG was observed when introducing the camera subumbilical after a pneumoperitoneum was created by Veress needle. LTH was normally positioned. We started dissection in order to create a critical view of safety. The cystic artery was dissected by coagulation and clips were placed. Next, we clipped the CBD. No further anatomic variations were observed and the cholecystectomy was performed without complications. A video of the procedure is available online following the link in Figure 1.
Role of team members
The team consisted of a gastrointestinal surgeon and a resident in surgery performing the surgical procedure. Furthermore, an anesthesiologist, an anesthesiology assistant and two surgical assistants were part of the team. Introduction of the trocars was done by the resident. The cholecystectomy was performed by the gastrointestinal surgeon.
Post-operatively the patient recovered swiftly and was discharged home the same day, within 6 weeks she returned to the outpatient clinic for wound inspection and check-up. No histological abnormalities were reported.
Multiple embryological explanations have been suggested for the existence of LSG without situs inverses. One theory describes the development of two gallbladders adjacent to the LTH during the early embryological stages. The main gallbladder on the right side of the LTH will show atrophy and eventually disappear. This concept explains a cystic duct which drains the left hepatic duct or the CBD on the left side. Another theory suggests that the gallbladder initially develops normally from the hepatic diverticulum, however, the connection with the developing left lobe of the liver induces a migration of the gallbladder to the left of the LTH (10). This modality explains the long cystic duct that crosses the CBD from left to right and drains the latter on the right side. None of the theories mentioned above can fully explain a T-LSG, the exact mechanism of the aberrant development of T-LSG remains unknown.
While some cases describe the identification of T-LSG pre-operatively, most cases with this congenital anomaly are discovered intra-operatively (11). Since the visceral pain fibers do no transpose with the gallbladder, a patient with T-LSG will still experience right upper quadrant abdominal pain radiating to the back with a positive Murphy’s sign with cholecystitis (12).
Although it is not possible to distinguish a T-LSG on clinical symptoms, it can be diagnosed with MRI or CT-cholangiography. A number of anatomical variations are associated with a T-LSG, i.e., complete or partial situs inverses, atrophy of hepatic segment IV, duplicated or hypoplasia of the CBD, intraportal bile ducts, and abnormal pancreato-biliary junction (13). If these variations are found on imaging, the presence of a T-LSG should be taken into account. Clarifying anatomy pre-operatively is paramount to ensure the surgeon is well prepared and the risk of complications is minimized.
LC on a T-LSG is associated with a higher risk on intra-operative and post-operative complications (14). This is partially due to the higher incidence of aberrant biliary anatomy in T-LSG, while abnormalities of the portovenous system are of less importance during LC (8). The inability to recognize a T-LSG can cause complications such as bile leakage, liver failure, and liver resection (15).
If T-LSG is diagnosed pre-operatively, the traditional LC port placing can be adjusted to ensure better exposure of Calot’s triangle and other critical structures (16). Different case reports have suggested altered port placing, such as mirror-image port placing on the left side, accessory port placing, modifications of the sub-xiphoid trocar, or a single-incision dual-port approach (17-20). While the patient is usually positioned left-side up with LC, when using the mirror-image port placing the patient can be placed in lithotomy to ensure better surgical accessibility (19,21). Some case reports suggest that when a T-LSG is diagnosed intra-operatively, an intra-operative cholangiogram should be performed to clarify biliary anatomy before the dissection of the T-LSG takes place (8,16). This dissection can be performed both normograde and fundus-first retrograde since no statement on the outcome has been made regarding the manner of dissection. Lastly, when critical view cannot be acquired, converting to an open resection is endorsed to minimize the risk of complications.
Tips, tricks and pitfalls
As demonstrated by this case report, it is possible to perform a LC with traditional port placement and patient positioning without pre-operative MRI or CT-cholangiography. However, to minimize the risk on intra- and postoperative risks we suggest an MRI- or CT-cholangiography is made when the aberrant anatomy is diagnosed pre-operatively. When the anomaly is found intra-operatively a cholangiogram may be performed in case of doubt. Regarding the port placement and patient positioning, there is no clear evidence to establish a certain preference, and this should be performed by surgeon’s preference in acquiring critical view of safety.
A T-LSG is a rare congenital anomaly that every surgeon performing LCs should be able to identify. Whether it is found pre-operatively or intra-operatively, effort should be taken to clarify biliary anatomy since T-LSG is associated with aberrant anatomy. This anomaly may increase the risk of intra- and postoperative complications. Regarding the LC, traditional patient positioning and port placement can be used. It should be performed by surgeons’ preference in order to acquire critical of safety.
Conflicts of Interest: The authors have no conflicts of interest to declare.
Informed Consent: Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images.
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Cite this article as: de Mooij K, Bakens M, de Loos E, Stoot J. A common procedure with a rare anatomical finding: a case report on a true left-sided gallbladder. J Vis Surg 2018;4:192.