Images in…
Laparoscopic cholecystectomy for a patient with a double gallbladder Mohammed Sulaiman Ali,1 Saad Muwafaq Attash2 1
Iraqi Ministry of Health, Mosul, Iraq 2 Department of Surgery, Nineveh Medical College, Mosul University, Mosul, Iraq Correspondence to Dr Saad Muwafaq Attash, [email protected]
DESCRIPTION A 43-year-old woman was referred with a 5-day history of epigastric and right upper quadrant pain associated with nausea. The patient had tenderness in the right hypochondrium on the abdominal examination. She had no jaundice. The leucocyte count and liver function tests were normal, ultrasonography of the abdomen revealed a distended, thick wall gallbladder with multiple small gallstones and normal diameter of the common bile duct and normal pancreas. The patient underwent laparoscopic cholecystectomy the next day. Intraoperatively the patient was found to have a double gallbladder with a single cystic duct (figures 1 and 2). The operation was completed in the usual way (video 1) and the histopathological examination of the specimen revealed a double gallbladder with completely separated lumens and a single cystic duct (figure 3), both lumens filled with multiple small stones with features of an acute inflammation in the two bladders. The patient was discharged home 24 h later. Double gallbladder is an unusual congenital biliary anomaly, occurring at the rate of 1/4000. Most cases are asymptomatic and may be missed. However, this anomaly may cause diagnostic and surgical problems in case of cholecystitis.1 Failure to detect the accessory gallbladder has been
Figure 2 Postoperative images of the specimen showing the double gallbladder, completely separated lumens with a single cystic duct. reported as resulting in repeated episodes of cholecystitis in the remaining gallbladder after cholecystectomy.2 The preoperative diagnosis of this anomaly is especially important to prevent possible surgical complications and repeated laparotomies. In recent years, gallbladder duplication has been detected easily by CT.3
To cite: Ali MS, Attash SM. BMJ Case Rep Published online: [ please include Day Month Year] doi:10.1136/ bcr-2013-200986
Figure 1 Postoperative images of the specimen showing the double gallbladder, completely separated lumens with a single cystic duct.
Ali MS, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-200986
Video 1 Operative video showing the double gallbladder. 1
Images in… Fortunately, in our case the double gallbladder was obviously associated with a single cystic duct, therefore intraoperative cholangiography was not required and the operation was completed as usual.
Learning points ▸ Gallbladder duplication is a rare congenital anomaly that is not associated with any specific symptoms. ▸ Gallbladder duplication may be easily missed with ultrasonography as in our case. ▸ Intraoperative identification of the accessory gallbladder is necessary to avoid recurrence of symptoms in the missed accessory gallbladder. ▸ Surgeons should be aware about the possibility of the presence of double cystic duct, in case of any doubt, intraoperative cholangiography should be used to better define the anatomy. Figure 3 Postoperative images of the specimen showing the double gallbladder, completely separated lumens with a single cystic duct. Competing interests None.
A double cystic duct in association with a double gallbladder is an extremely rare variation.4 During laparoscopic cholecystectomy, if the surgeon suspects the presence of more than one cystic duct, then intraoperative cholangiography is highly recommended to define the anatomy clearly and to exclude the possibility of an accessory cystic duct which needs to be clipped or ligated to avoid postoperative leak, and to exclude the possibility of an injury to the bile ducts which might necessitate conversion into laparotomy to be assessed and dealt with accordingly.
Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2 3
4
Gross RE. Congenital anomalies of the gall-bladder. A review of 148 cases with a report of double gall-bladder. Arch Surg 1936;32:131–59. Silvis R, Van Wieringen AJ, Van Der Werken CH. Re-operation for symptomatic double gall-bladder. Surg Endosc 1996;10:336–7. Urbain D, Jeanmort J, Janne P. Double gallbladder with transient cholestasis: preoperative demonstration by endoscopic retrograde cholangiopancreatography. Gastrointest Endosc 1980;35:346–8. Huston TL, Dakin GF. Double cystic duct. Can J Surg 2008;51:E8–10.
Copyright 2013 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
2
Ali MS, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-200986
Laparoscopic cholecystectomy for a patient with a double gallbladder Mohammed Sulaiman Ali,1 Saad Muwafaq Attash2 1
Iraqi Ministry of Health, Mosul, Iraq 2 Department of Surgery, Nineveh Medical College, Mosul University, Mosul, Iraq Correspondence to Dr Saad Muwafaq Attash, [email protected]
DESCRIPTION A 43-year-old woman was referred with a 5-day history of epigastric and right upper quadrant pain associated with nausea. The patient had tenderness in the right hypochondrium on the abdominal examination. She had no jaundice. The leucocyte count and liver function tests were normal, ultrasonography of the abdomen revealed a distended, thick wall gallbladder with multiple small gallstones and normal diameter of the common bile duct and normal pancreas. The patient underwent laparoscopic cholecystectomy the next day. Intraoperatively the patient was found to have a double gallbladder with a single cystic duct (figures 1 and 2). The operation was completed in the usual way (video 1) and the histopathological examination of the specimen revealed a double gallbladder with completely separated lumens and a single cystic duct (figure 3), both lumens filled with multiple small stones with features of an acute inflammation in the two bladders. The patient was discharged home 24 h later. Double gallbladder is an unusual congenital biliary anomaly, occurring at the rate of 1/4000. Most cases are asymptomatic and may be missed. However, this anomaly may cause diagnostic and surgical problems in case of cholecystitis.1 Failure to detect the accessory gallbladder has been
Figure 2 Postoperative images of the specimen showing the double gallbladder, completely separated lumens with a single cystic duct. reported as resulting in repeated episodes of cholecystitis in the remaining gallbladder after cholecystectomy.2 The preoperative diagnosis of this anomaly is especially important to prevent possible surgical complications and repeated laparotomies. In recent years, gallbladder duplication has been detected easily by CT.3
To cite: Ali MS, Attash SM. BMJ Case Rep Published online: [ please include Day Month Year] doi:10.1136/ bcr-2013-200986
Figure 1 Postoperative images of the specimen showing the double gallbladder, completely separated lumens with a single cystic duct.
Ali MS, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-200986
Video 1 Operative video showing the double gallbladder. 1
Images in… Fortunately, in our case the double gallbladder was obviously associated with a single cystic duct, therefore intraoperative cholangiography was not required and the operation was completed as usual.
Learning points ▸ Gallbladder duplication is a rare congenital anomaly that is not associated with any specific symptoms. ▸ Gallbladder duplication may be easily missed with ultrasonography as in our case. ▸ Intraoperative identification of the accessory gallbladder is necessary to avoid recurrence of symptoms in the missed accessory gallbladder. ▸ Surgeons should be aware about the possibility of the presence of double cystic duct, in case of any doubt, intraoperative cholangiography should be used to better define the anatomy. Figure 3 Postoperative images of the specimen showing the double gallbladder, completely separated lumens with a single cystic duct. Competing interests None.
A double cystic duct in association with a double gallbladder is an extremely rare variation.4 During laparoscopic cholecystectomy, if the surgeon suspects the presence of more than one cystic duct, then intraoperative cholangiography is highly recommended to define the anatomy clearly and to exclude the possibility of an accessory cystic duct which needs to be clipped or ligated to avoid postoperative leak, and to exclude the possibility of an injury to the bile ducts which might necessitate conversion into laparotomy to be assessed and dealt with accordingly.
Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2 3
4
Gross RE. Congenital anomalies of the gall-bladder. A review of 148 cases with a report of double gall-bladder. Arch Surg 1936;32:131–59. Silvis R, Van Wieringen AJ, Van Der Werken CH. Re-operation for symptomatic double gall-bladder. Surg Endosc 1996;10:336–7. Urbain D, Jeanmort J, Janne P. Double gallbladder with transient cholestasis: preoperative demonstration by endoscopic retrograde cholangiopancreatography. Gastrointest Endosc 1980;35:346–8. Huston TL, Dakin GF. Double cystic duct. Can J Surg 2008;51:E8–10.
Copyright 2013 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
2
Ali MS, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-200986
