A ‘twist’ in the tale of a ‘simple’ laparoscopic cholecystectomy: Duplication of the gall bladder

Abstract

The duplication of the gall bladder (GB) is unusual biliary anatomy that can be encountered during cholecystectomy and can create intraoperative confusion if missed on pre-operative imaging. Here, we describe a case of duplication of GB in a young female, which was detected during laparoscopic cholecystectomy as an operative surprise. Laparoscopic cholecystectomy was done successfully with the removal of both the GBs. She was discharged uneventfully and remained symptom-free at a 6-month follow-up.

INTRODUCTION

Duplication of the gall bladder (GB) is an uncommon congenital anomaly with an incidence of 1:4000 births.[1] These anomalies can be associated with the development of cholelithiasis due to inadequate GB emptying. Awareness of different variations of biliary tree and recognition during radiological evaluation and surgery plays an important role in avoiding post-operative bile leaks and preventing re-operation if accessory GB has been missed during primary surgery. Ultrasonography (USG) can frequently miss the diagnosis, which may be due to a smaller accessory GB or lack of distension of the GB due to improper fasting. Here, we present a case of duplication of the GB, discovered during laparoscopic cholecystectomy.

CASE REPORT

A 38-year-old female presented with a 3-month history of recurrent biliary colic. The abdominal examination was unremarkable. The liver function test (LFT) was normal. USG revealed a distended, thin-walled GB with multiple gallstones. There was no suspicion of a double GB on USG [Figure 1a].

Figure 1.

(a) Ultrasonography images showed the presence of gallstones; however, duplication of the gall bladder was not obvious. (b) The critical view of safety was achieved. Two cystic ducts (red and blue arrows) were clipped and partially cut

As both the GB was covered with a single peritoneal lining, it was not apparent while dividing the anterior and posterior peritoneal attachments of the GB during cholecystectomy. While the GB was dissected from the liver bed, exposing the cystic plate, two tubular biliary structures (<3 mm) were encountered that were directly joining with the GB, which raised suspicion of a double gall bladder. After the dissection of the hepatocystic triangle, both the ducts were clipped and cut [Figure 1b]. Both the GBs were fused along their entire length, with two separate cystic ducts joining into common bile duct (CBD). The specimen was examined after extraction, which confirmed the presence of two GBs. Gallstones were present in both the GBs [Figure 2]. She was discharged on the next day, and histopathology revealed two separate GBs with features of chronic cholecystitis. The patient remained asymptomatic at 6-month follow-up.

Figure 2.

(a) Specimen: Both the GBs and cystic ducts were cannulated with probes. (b) Specimen: Both the gallbladders were cut open and stones (blue arrow) were extracted and probes were passed through both cystic ducts (red arrow)

DISCUSSION

The aetiopathogenesis of GB duplication is unknown; Boyden[2] reported that numerous outgrowths and accessory vesicles are developed during embryogenesis’s 5^th to 6^th weeks to form a ductal system known as the hepatic antrum. These supernumerary buds generally regress, but they may persist and result in the formation of duplication of the GB.[2] Other theories postulated that splitting of cystic primordium and accessory cystic primordium results in duplication.[3]

Harlaftis[3] classification is still used most widely and classifies the duplicated GBs anomalies into two types: Type 1 (split primordium GB-single cystic duct) and Type 2 (accessory GB-separate cystic duct joining CBD. Our case represents the most common Type 2; H-type double gall bladder variation.

Although the imaging quality and expertise have improved dramatically, the diagnosis of double GB can be missed. (USG) being operated dependent is an inherent limitation. Magnetic resonating cholangiopancreatography (MRCP) should be advised when duplicated GB is suspected and can give a clear picture of biliary anatomy. However, MRCP is usually not done before routine laparoscopic cholecystectomy without a history of jaundice or deranged liver function test.

As a surgeon, it is important to know all the variations of the GB anatomy and its interpretation during cholecystectomy. Removal of all accessory GBs is necessary to prevent future gallstones or cholecystitis in the leftover GB. The persistence of biliary symptoms has been reported after inadequate removal of duplicated GB.[4] Reinisch et al. described a case where laparoscopic cholecystectomy was required because of acute cholecystitis of the remaining duplicated GB, 17 years after open cholecystectomy.[5]

Although biliary anomaly possesses a higher risk of injury to CBD or bile leak, GB anomalies can safely be completed laparoscopically, unless they are deeply intrahepatic. Application of the principles of laparoscopic cholecystectomy, i.e., clearing all fibrofatty tissues in a hepatocystic triangle, dissecting the GB off the liver bed widely exposing the cystic plate, and identification of the infundibulum–cystic duct junctions are the keys to success and safety. However, intraoperative cholangiogram and indocyanine green fluorescence cholangiography can further aid in the identification of biliary and GB anatomy.

In conclusion, GB duplication is a rare anomaly and every attempt should be made to recognise it before the operating room to avoid unnecessary intraoperative confusion. However, awareness of the anomalies and sticking to the principles of laparoscopic cholecystectomy can safely tackle such intraoperative surprises and are the keys to a successful post-operative outcome.

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 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.