Duplication of the gallbladder: An intraoperative finding during laparoscopic cholecystectomy

Abstract

Introduction

Duplication of the gallbladder is a rare congenital malformation associated with the development of cholelithiasis. It increases the risk of iatrogenic bile duct injury during cholecystectomy and can lead to symptom recurrence if missed. Although preoperative imaging is helpful, detection rates are around 50 %.

Case presentation

A 36-year-old healthy female with symptomatic gallstone disease and ultrasonographic evidence of cholelithiasis was scheduled for elective laparoscopic cholecystectomy. Following standard four port entry and dissection of pericholecystic adhesions to duodenum, a V shaped duplicated gallbladder with calculi, and a common cystic duct and artery was noted. The cystohepatic triangle was dissected, critical view of safety demonstrated and the common cystic duct and artery were divided between clips.

Discussion

Variations in gallbladder morphology has been described by Gross, Boyden and Harlaftis classification. Type 1 (bilobed gallbladder) has a common embryological origin with an invaginating septum separating the lumens while type 2 (double gallbladder) has a double embryological origin with separate gallbladders and their own cystic ducts. Many cases go undetected or are mis-identified as choledochal cyst, diverticulum or Phrygian cap. MRCP is the imaging modality of choice for suspected duplicate gallbladder.

Conclusion

Careful dissection of the cystohepatic triangle with attention to critical view of safety is important in all cases as numerous variations in hepatobiliary anatomy have been described. Surgical awareness of these variations and good surgical technique will promote safe laparoscopic cholecystectomy even in the most unexpected of encounters.

Highlights

• •Anatomical variations in the gallbladder, cystic duct and cystic artery are associated with a higher degree of complications during laparoscopic cholecystectomy.
• •Duplication of the gallbladder is a rare congenital malformation with an incidence of 1 in 4000 births.
• •The presence of cystic lesions adjacent to the gallbladder on imaging should raise the suspicion of a gallbladder anomaly.
• •Surgical awareness of these variations and good surgical technique will promote safe laparoscopic cholecystectomy.

1. Introduction

Duplication of the gallbladder is a rare congenital malformation that occurs in 1 in 3800–4000 births. Such anatomical variations in the gallbladder, cystic duct and cystic artery are associated with a higher degree of complications during laparoscopic cholecystectomy and are considered to be one of the important risk factors for iatrogenic bile duct injury during cholecystectomy especially laparoscopic cholecystectomy. These malformations could be associated with the development of cholelithiasis, due to inadequate bile drainage [1].

Although gallbladder duplication was initially classified by Boyden, the Harlaftis classification is surgically more relevant and universally accepted. The more common variant is type-1 and it occurs due to a split primordium while type-2, often called accessory gallbladder, arises from the formation of a double primordium during 5th and early 6th weeks of embryogenesis [2,3].

Surgeons unaware of this anatomical anomaly can run into intraoperative and postoperative complications that includes missing the 2nd gallbladder leading to symptom recurrence and reoperation. This case report was reported in view to increasing awareness of gallbladder duplication and has been reported in line with SCARE guidelines 2023 [[4], [5], [6], [7]].

2. Case

A 36-year-old healthy Sri Lankan female presented to the surgical clinic with a history of recurrent biliary colic and one episode of acute cholecystitis over a 6-month period. She had with no significant medical or surgical history, was a housewife, a non-smoker and a teetotaler. General and abdominal examinations were unremarkable. Liver function tests including serum bilirubin levels and alkaline phosphatase were in normal range. Transabdominal ultrasound scans demonstrated multiple gallbladder calculi without evidence of intra or extrahepatic duct dilatation. She was scheduled for a routine elective laparoscopic cholecystectomy. On admission, she had mild right upper quadrant tenderness, but was otherwise well. Liver biochemistry was normal.

The patient was positioned supine, administered general anesthesia and the laparoscopic cholecystectomy was commenced using sub-umbilical open entry with conventional four port access and pneumoperitoneum at 12 mmHg. Multiple pericholecystic adhesions as well as adhesions between the duodenum and the gallbladder were seen. Upon meticulous dissection, the patient was noted to have a V shaped duplication of the gallbladder with a common cystic duct and artery (Fig. 1), with calculi in each gallbladder. Intraoperative cholangiography is not available in our setting and hence the principles of safe laparoscopic cholecystectomy were adhered to. The cystohepatic triangle was dissected and critical view of safety demonstrated. (Fig. 2) The common cystic duct and artery were divided between clips and the specimen delivered through the laparoscopic port. She had an uneventful postoperative period and was discharged the following day. Histopathological examination revealed chronic cholecystitis with cholelithiasis.

Fig. 1.

Intraoperative detection of a V shaped duplicated gallbladder with a common cystic duct.

Fig. 2.

Demonstration of critical view of safety.

3. Discussion

Duplication of the gallbladder is a rare congenital malformation with an incidence of 1 in 4000 births [8]. Its true incidence may however be higher as cases are detected either incidentally at autopsy, during imaging while investigating for symptomatic cases or during surgery [9]. Variations in gall bladder morphology have been described and classified by Gross, Boyden and Harlaftis [10,11]. They can broadly be classified into 2 main types, type 1 or the bi-lobed gallbladder (Vesica fellea divisum), where both gallbladders share a common embryological origin (primordium) in which a longitudinal septum or invaginating cleft separates the lumen into 2 chambers. The second, type 2 or the double gallbladder (Vesica fellea du-plex), has a double embryological origin with 2 separate gallbladders, each with their own cystic ducts. In our case, there was a type 1, V shaped double gallbladder with a common cystic duct and cystic artery.

Preoperative diagnosis is helpful, but on transabdominal ultrasonography many cases go undetected or are mistakenly identified as a choledochal cyst, gallbladder diverticulum, or Phrygian cap. The presence of cystic lesions adjacent to the gallbladder on imaging should raise the suspicion of a gallbladder anomaly. Magnetic Resonance Cholangiopancreatography (MRCP) is the imaging modality of choice for suspected duplicate gallbladder. Further diagnostic preoperative imaging will help prevent surprises, reduce intraoperative complications and overlooking the second gallbladder [12]. However, as most cases go undetected, intraoperative recognition is common. Use of intraoperative cholangiography (IOC) will reveal duplication but there are no studies assessing its utility.

Diseases that plague the single gallbladder such as symptomatic gallstone disease; acute or chronic cholecystitis, empyema, fistula, and other pathologies such as papilloma and carcinoma have been described in duplicated gallbladders as well [[13], [14], [15], [16], [17], [18]]. However the commonest complication is cholelithiasis.⁶ Hence, simultaneous removal of both gallbladders at surgery is recommended.

Duplicate gallbladder has been successfully treated by laparoscopic cholecystectomy and is the procedure of choice [[19], [20], [21]]. Overall, the risks associated with laparoscopic cholecystectomy for duplicate gallbladders are comparable to those with non-duplicate gallbladder. However, these cases probably do better in the hand of an experienced laparoscopic surgeon or a hepatobiliary surgeon [12].

4. Conclusion

Careful dissection of the cystohepatic triangle with attention to critical view of safety is important in all cases as numerous variations in hepatobiliary anatomy have been described. Surgical awareness of these variations and good surgical technique will promote safe laparoscopic cholecystectomy even in the most unexpected of encounters.

CRediT authorship contribution statement

1. Deshan Mario Gomez - Writing – original draft, Writing – review and editing, Visualization.

2. Arulprashanth Arulnathan - Writing – review and editing.

3. Dharmabandhu Nandadeva Samarasekera - Writing – review and editing.

4. Duminda Subasinghe - Writing – review and editing, supervision.

Informed consent

Written informed consent was obtained from the patient's parents/legal guardian for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

NHSL Ethics review committee: Ethical approval was deemed unnecessary by the institutional ethics committee as the paper reports a single case that emerged during normal practice.

Guarantor

Deshan Gomez

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Registration of research studies

N/A.

Declaration of competing interest

The Author(s) declare(s) that there is no conflict of interest.