Abstract
Introduction and importance:
Left-sided gallbladder (LSG) without situs inversus is a rare anatomical variant, which is recognized by the gallbladder being located left to the falciform ligament. It is often detected incidentally during surgery. Failure to recognize this variant may increase the risk of bile duct injury.
Case presentation:
This is the case report of a 42-year-old woman who presented with swelling around the umbilical region for 6 months. Ultrasonography of the abdomen and pelvis showed an umbilical hernia with cholelithiasis but failed to detect the left-sided position of the gallbladder. She was then planned for elective laparoscopic cholecystectomy with primary repair of the umbilical hernia. Intraoperatively, the gallbladder was found left to the falciform ligament. Intraoperative cholangiography was not done. Laparoscopic cholecystectomy was completed using the standard four-port technique without additional port placement. Primary repair of the umbilical hernia was also done in the same operative setting. The postoperative course was uneventful, and the patient was discharged on postoperative day 2. Patient remained asymptomatic without any complications on follow-up at 2 and 4 weeks postoperatively.
Discussion:
LSG is uncommon and may not be detected on preoperative imaging but when discovered incidentally during laparoscopic cholecystectomy, it can be managed safely with or without any modifications. This case highlights safe completion of surgery without additional port placement after clear identification of biliary anatomy with simultaneous umbilical hernia repair.
Conclusion:
Surgeons should be aware of LSG as a potential anatomical variation and adopt cautious dissection strategies that may require modifications of laparoscopic techniques to prevent iatrogenic injury to surrounding structures.
Keywords: anatomical variant, case report, laparoscopic cholecystectomy, left-sided gallbladder, sinistroposition
Introduction
Left-sided gallbladder (LSG) is a rare anatomical variant with reported incidence from 0.2% to 1.1%[1]. It is defined as a gallbladder located left to the falciform ligament, first described by Cirla and De Vecchi[2]. Several anomalies of the portal vein and biliary system are associated with LSG[3,4]. There are three variants of LSG recognized in literature, which are – True LSG, known as sinistroposition, gallbladder located to the left of an abnormally located right round ligament known as medioposition, and LSG associated with situs inversus[3,5]. Usually, LSG without situs inversus is discovered incidentally during surgery[6].
HIGHLIGHTS
A true left-sided gallbladder is a rare anatomical variant.
It is often diagnosed intraoperatively, as preoperative imaging may not identify it.
The relationship of gallbladder fossa to the falciform ligament is a key diagnostic landmark.
Laparoscopic cholecystectomy can be safely completed with or without modification of standard port placement.
Here, we present a case of a middle-aged woman with LSG (sinistroposition) without situs inversus that was not detected on preoperative ultrasonography and only identified intraoperatively during elective laparoscopic cholecystectomy with primary umbilical hernia repair. The procedure was completed laparoscopically using the standard port configuration without modification. These features highlight the importance of intraoperative anatomical awareness and careful dissection even during procedures as routine as laparoscopic cholecystectomy.
This case report has been reported in line with SCARE checklist[7].
Case presentation
Preoperative course
A 42-year-old woman with P2L2 and a BMI of 19 kg/m2 presented to the surgery outpatient department with swelling around the umbilical region for 6 months, which was insidious in onset, non-progressive, non-painful, more prominent on coughing, and reducible on lying down. There was no history of vomiting, abdominal distension, right upper quadrant pain, constipation, fever, and discoloration of the overlying skin. She had no known history of hypertension, chronic obstructive pulmonary disease, and diabetes mellitus. There was no history of any surgical intervention in the past. She had no history of allergies to food or drugs. She did not smoke or consume alcohol. She was living with her family and was independent in her activities of daily living. There was no recent travel history.
On examination, she was well-looking, conscious, cooperative, and well oriented to time, place, and person with a Glasgow Coma Scale score of 15/15. Her vitals were: pulse – 84 bpm, BP – 120/90 mmHg, RR – 18 breaths/min, SpO2 – 98% in room air, and temperature – 98°F. She had no pallor, icterus, cyanosis, clubbing, edema, and signs of dehydration. On systemic examination, the central nervous system was grossly intact. Chest was clear with the presence of bilateral equal air entry. On cardiovascular examination, normal heart sounds were heard without any murmurs. On per abdominal examination, a single, rounded swelling was present at the umbilical region, measuring approximately 3 × 3 cm with normal overlying skin. Umbilicus was everted, and a cough impulse was present. On palpation, swelling was soft in consistency with a smooth surface without any tenderness and local rise in temperature. On reduction, a defect of approximately 1 cm was felt. A dull note was heard on percussion. There was no right upper quadrant tenderness, and Murphy’s sign was negative.
The differential diagnosis for the umbilical swelling included umbilical hernia, epigastric hernia, paraumbilical hernia, lipoma of the abdominal wall, and less commonly an umbilical cyst or other soft tissue lesion. Clinical examination was suggestive of a reducible umbilical hernia, which was subsequently confirmed on ultrasonography.
Baseline investigations were sent and summarized in Table 1. Ultrasonography of the abdomen and pelvis was done, which showed herniation of omental fat content with intact vascularity through a defect measuring 13 mm, visualized in the subcutaneous tissue of the umbilical region. There was incidental visualization of a single gallbladder calculus measuring 9.6 mm (Fig. 1). Chest X-ray posteroanterior view was normal (Fig. 2). Preoperative working diagnosis of umbilical hernia with cholelithiasis was made. Further cross-sectional imaging modalities like computed tomography and magnetic resonance cholangiopancreatography (MRCP) were not done, as ultrasonography showed cholelithiasis with no features, suggesting an anatomical abnormality. There was no reason to suspect biliary anomalies. She was then planned for elective laparoscopic cholecystectomy with primary repair of umbilical hernia in the same sitting. Pre-anesthetic checkup was done, and the patient was assessed as fit for surgery. She was admitted to the surgery ward the day before and kept nil per oral from midnight.
Table 1.
Preoperative baseline laboratory investigations with reference ranges.
| Test | Result | Reference range |
|---|---|---|
| Complete blood count | ||
| Hemoglobin | 136 g/L | 110–160 g/L |
| WBC count | 10.89 × 109 cells/L | 4–11 × 109 cells/L |
| Neutrophils | 53% | 40–80% |
| Lymphocytes | 38% | 20–40% |
| Eosinophils | 5% | 1–6% |
| Platelets | 378 × 109 cells/L | 150–400 × 109 cells/L |
| RBC count | 4.51 × 1012 cells/L | 4.2–6 × 1012 cells/L |
| Renal function test | ||
| Serum creatinine | 61 µmol/L | 53–115 µmol/L |
| Serum urea | 7.5 mmol/L | 2.5–7.8 mmol/L |
| Serum sodium | 139 mmol/L | 135–145 mmol/L |
| Serum potassium | 4.2 mmol/L | 3.5–5.1 mmol/L |
| Random serum glucose | 4.9 mmol/L | 3.9–7.8 mmol/L |
| Liver function test | ||
| Aspartate transaminase | 19 U/L | 5–35 U/L |
| Alanine transaminase | 21 U/L | 5–45 U/L |
| Alkaline phosphatase | 65 U/L | 38–126 U/L |
| Total protein | 73 g/L | 60–83 g/L |
| Serum albumin | 44 g/L | 35–50 g/L |
| Total bilirubin | 10.3 µmol/L | 3.4–22 µmol/L |
| Direct bilirubin | 3.4 µmol/L | 0.0–5.1 µmol/L |
Figure 1.
Ultrasonography of the abdomen showing a single calculus measuring 0.96 cm (black arrow).
Figure 2.
Normal chest X-ray posteroanterior view.
Intraoperative course
The patient underwent an elective laparoscopic cholecystectomy with concurrent primary repair of umbilical hernia under general anesthesia. The patient was positioned supine on the operating table with the surgeon standing on the left side of the patient and the assistant on the right. A single dose of prophylactic intravenous antibiotics was administered prior to skin incision. Under all aseptic conditions and precautions, the abdomen was painted and draped after induction of anesthesia.
Pneumoperitoneum was established using a closed Veress needle technique through the umbilicus, and intra-abdominal pressure was maintained at 12 mmHg. A 10 mm camera port was inserted at the umbilicus, and diagnostic laparoscopy was performed. On initial inspection, the gallbladder was noted to be attached to the left lobe of the liver, positioned to the left of the falciform ligament, consistent with true LSG (sinistroposition). To improve exposure of the operative field, the falciform ligament was divided using electrocautery. Under direct laparoscopic visualization, a 10 mm epigastric working port was placed in the midline inferior to the xiphoid process. Two additional 5 mm ports were inserted in the right mid-clavicular line and right anterior axillary line, respectively, in a manner similar to the standard four-port laparoscopic cholecystectomy technique.
The gallbladder was retracted to expose Calot’s triangle, which was located slightly leftward relative to the falciform ligament, but did not demonstrate a mirror-image configuration. Careful dissection of Calot’s triangle was performed using a combination of blunt dissection and electrocautery. The cystic duct and cystic artery were identified, and the critical view of safety was achieved, with clear visualization of two structures entering the gallbladder and complete dissection of the lower third of the gallbladder from the liver bed. The cystic duct and cystic artery demonstrated expected anatomical relationships with mild alteration in spatial orientation due to the left-sided position of the gallbladder, but no abnormal insertion was noted. Both structures were secured with titanium clips and divided. During the dissection of the gallbladder from the gallbladder fossa, it was retracted medially by a grasper via epigastric port and dissected by hook via the third mid-clavicular port while giving careful attention to achieve hemostasis. The specimen was placed in a laparoscopic specimen retrieval bag and extracted through the epigastric port site (Fig. 3).
Figure 3.
Intraoperative laparoscopic view showing the gallbladder bed lying on the left of falciform ligament.
Attention was then directed to the umbilical hernia. A fascial defect measuring approximately 1 cm containing preperitoneal fat was identified. The hernia contents were reduced into the peritoneal cavity, and the fascial defect at the level of the anterior rectus sheath was closed primarily using interrupted non-absorbable polypropylene (Prolene 0) sutures. Given the small size of defect (1 cm), mesh reinforcement was not considered.
The abdominal cavity was irrigated and inspected, confirming adequate hemostasis and absence of bile leakage. Pneumoperitoneum was released, and the ports were removed under direct vision. The fascial defect at the 10 mm port sites was closed, and skin incisions were approximated with sutures. Sterile dressings were applied.
The total operative time was approximately 60 min, with minimal estimated blood loss (20 mL). No intraoperative complications occurred.
Final diagnosis was true LSG (sinistroposition) with cholelithiasis and umbilical hernia.
Postoperative course
The patient was monitored postoperatively in the surgical intensive care unit (SICU) as per institutional protocol for combined procedures for 1 day. The ICU stay was precautionary and not related to the presence of LSG or intraoperative complications. The patient was then shifted to a ward. Oral intake was resumed as tolerated. Postoperative pain was adequately controlled with multimodal analgesia consisting of bilateral subcostal transversus abdominis plane block with systemic non-steroidal anti-inflammatory drugs. The postoperative course was uneventful. The patient recovered well with no evidence of postoperative complications. The patient was discharged in a stable condition on postoperative day 2 with advice for dressing every third day, avoiding strenuous work and fatty foods, and suture removal on postoperative day 10.
At the 2-week follow-up visit, the patient was asymptomatic with well-healed port-site and umbilical wounds and no evidence of surgical site infection. At the 30-day follow-up, the patient remained symptom-free with no evidence of biliary complications or recurrence of the umbilical hernia. Histopathology report of the sample showed chronic cholecystitis with cholelithiasis.
This surgery was performed in a tertiary care center where such cases are routinely managed. The operating surgeon had prior experience in managing such cases.
Timeline
| Date | Event |
|---|---|
| 28 December 2025 | A patient presented to the surgical outpatient department with umbilical swelling. Baseline investigations were performed. Ultrasonography revealed an umbilical hernia with incidental cholelithiasis. The patient was counseled for a laparoscopic cholecystectomy with simultaneous primary repair of the umbilical hernia. Pre-anesthetic evaluation was completed. |
| 1 January 2026 | The patient was admitted to the surgical ward for planned surgery. Preoperative preparation was completed, and the patient was kept nil per oral from midnight. |
| 2 January 2026 | An elective laparoscopic cholecystectomy with primary repair of umbilical hernia was performed. The patient was shifted to the SICU for postoperative monitoring. |
| 3 January 2026 | The patient was transferred from the ICU to the surgical ward after stable recovery. |
| 4 January 2026 | The patient was discharged in stable condition with no postoperative complications. |
| 16 January 2026 (2-week follow-up) | The patient was reviewed in an outpatient clinic. Wounds were well healed with no signs of infection or complications. |
| 2 February 2026 (30-day follow-up) | The patient remained asymptomatic with no biliary complications or evidence of umbilical hernia recurrence. |
Discussions
The gallbladder is a pyriform-shaped organ that stores and concentrates the bile produced by the liver[8]. It is typically located in the gallbladder fossa in between Couinaud liver segments 4b and 5. In rare instances, it may be ectopic and thus may be intrahepatic, transverse, retro-displaced, and left-sided in location[5,9].
It develops as an endodermal outgrowth from the ventral aspect of foregut as a cystic diverticulum just caudal to the hepatic duct and cephalad to the ventral pancreatic bud during the fourth week of development[10]. The embryological basis for the LSG without situs inversus is still unknown. Various theories have been described in literature for true LSG, also called sinistroposition, like our case. The first theory states that the gallbladder develops from endodermal outgrowth at its normal site, which gets attached to the developing left lobe and therefore causes migration of the gallbladder to the left lobe of liver, resulting in a long cystic duct that crosses in front of the common hepatic duct from right to left. The second theory states that the gallbladder develops on either side of the liver lobes, with the right-sided gallbladder becoming atrophic and disappearing[6,9,11].
It is worth noting that visceral pain fibers are not transposed along with the gallbladder, as it is innervated by right-sided sympathetic fibers[12]. Therefore, patients with LSG most often present with symptoms like right upper quadrant or epigastric pain that are indistinguishable from those of normally positioned gallbladder pathology, and suspicion is rarely raised prior to surgery[13].
Preoperative diagnosis is uncommon. Routine preoperative imaging like ultrasonography is often unreliable in this regard[5], as the primary focus is on identifying cholelithiasis, gallbladder wall changes, and bile duct pathology, rather than anatomical localization, and is operator dependent.
Advanced imaging modalities like computed tomography or MRCP and angiography may be used to increase the accuracy of preoperative diagnosis[12]. However, they are not routinely done unless there is complicated disease pathology or anatomy. Therefore, the majority of LSG cases are identified incidentally during surgery[11].
Anomalies like duplication of the common bile duct (CBD), hypoplastic CBD, infra-portal bile duct, and embedding of gallbladder in ectopic gallbladder bed are associated with ectopic gallbladder positions, which is significant, especially in LSG. These anomalies create significant operative challenges and are associated with increased risk of complications[5,14].
LSG can be safely removed with laparoscopic cholecystectomy whenever indicated, with or without a few modifications[5]. Placing an extra port at Palmer’s point, positioning ports in a mirror image of a right-sided standard laparoscopic cholecystectomy, using harmonic scalpels while resecting an impacted gallbladder in an ectopic gallbladder fossa, and performing intraoperative cystic duct cholangiography are some of the modifications described to prevent complications[15,16].
In our case, ultrasonography incidentally revealed cholelithiasis during evaluation of an umbilical hernia. As the patient was already scheduled for elective surgical repair of the hernia, laparoscopic cholecystectomy was planned during the same operative session after appropriate counseling and informed consent. It reflects a real-world surgical scenario where multiple conditions may be addressed in a single procedure.
During surgery, the gallbladder bed was identified to the left of falciform ligament, thereby confirming sinistroposition. The cystic duct and artery maintained their expected anatomical relationship with mild alteration in spatial orientation but without unusual insertion, allowing safe dissection after achieving the critical view of safety. The procedure was completed laparoscopically using the standard port configuration, with careful identification of anatomical landmarks, particularly the relationship of the gallbladder fossa to the falciform ligament. Intraoperative cholangiography was not performed in this case because the cystic duct and cystic artery were clearly identified, and the critical view of safety was achieved prior to division of the cystic structures. In addition, intraoperative cholangiography is not routinely available at our center; therefore, additional imaging was not considered necessary.
Postoperative cross-sectional imaging was not performed as the patient had an uneventful recovery with no clinical or biochemical evidence of biliary injury or obstruction. In the absence of symptoms or abnormal liver function tests, further imaging was not considered necessary.
Several case reports describing LSG have reported intraoperative diagnosis with varying surgical strategies, including modification of port placement or use of intraoperative cholangiography to visualize biliary anatomy. A comparison with some previously reported cases is summarized in Table 2[12,17–19].
Table 2.
Comparison with previously reported cases of left-sided gallbladder.
| Study | Preoperative diagnosis | Port modification | Intraoperative cholangiography | Operative outcome |
|---|---|---|---|---|
| Wong et al, 2001[19] | Not detected preoperatively | – | Not performed | Open subtotal cholecystectomy with left hepaticodochojejunostomy and hepaticojejunostomy due to injury of the CBD and left hepatic duct |
| Saafan et al, 2013[18] | Not detected on ultrasound | No modification | Not performed | Laparoscopic cholecystectomy completed successfully |
| Nagendran et al, 2013 | Not detected on ultrasound but diagnosed via MRI preoperatively | Yes – additional port used | Not performed | Laparoscopic cholecystectomy completed successfully |
| Iskandar et al, 2013[12] | Intraoperative diagnosis | Yes – altered port placement | Not reported | Laparoscopic cholecystectomy completed successfully |
| Zoulamoglou et al, 2017[17] | Not diagnosed preoperatively | Yes – ports repositioned | Not performed | Laparoscopic cholecystectomy completed successfully |
| Present case | Not detected on ultrasound | No modification | Not performed | Laparoscopic cholecystectomy completed with concurrent umbilical hernia repair |
Strengths and limitations
This case adds to the existing literature by reporting a rare but surgically relevant anatomical variant of the gallbladder. The diagnosis of LSG was confirmed by the gallbladder fossa lying left to the falciform ligament, a well-recognized anatomical landmark. Laparoscopic cholecystectomy was completed successfully without any modification of standard port placement and without conversion to open cholecystectomy.
A limitation of this case report is the absence of preoperative cross-sectional imaging and intraoperative pre-resection photographs. However, this reflects the incidental nature of the diagnosis and is consistent with many previously published case reports. As with all single case reports, its findings cannot be generalized. Intraoperative cholangiography was not performed in this case, resulting in limited visualization of the biliary tree.
Conclusions
LSG should be suspected when unusual biliary anatomy is encountered during laparoscopic cholecystectomy. Identification of the gallbladder fossa in relation to the falciform ligament is key to diagnosis. Careful dissection and adherence to the critical view of safety must be done for the completion of laparoscopic surgery with or without any port modification.
Acknowledgements
We thank the patient and the patient’s party for providing consent to share this case.
Footnotes
Sushan Ghimire and Salina Subedi contributed equally and share first authorship.
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Published online 29 April 2026
Contributor Information
Sushan Ghimire, Email: sushanghimire44@gmail.com.
Salina Subedi, Email: subedisalina2030@gmail.com.
Sushil Mishra, Email: drsushil065@gmail.com.
Binod Bade Shrestha, Email: badebinod@gmail.com.
Mrigendra Raj Pandey, Email: mrigendrarajpandey@gmail.com.
Ethical approval
Ethical approval was not required for this case report according to the policies of our institution, as it involves a single patient and does not constitute research involving human participants.
Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images. The patient was informed about the nature of the publication, and all identifying information has been removed to ensure confidentiality. A copy of the written consent is available for review by the Editor-in-Chief of this journal upon request.
Sources of funding
No external funding was received for this case report.
Author contributions
S.G.: concept, design, manuscript writing, editing, literature review, and manuscript review. S.S.: concept, design, manuscript writing, editing, literature review, and manuscript review. S.M.: concept, manuscript editing, literature review, and manuscript review. B.B.S.: design, manuscript writing, editing, and manuscript review. M.R.P.: design, manuscript writing, editing, and manuscript review.
Conflicts of interest disclosure
The authors declare no conflicts of interest related to the publication of this case report.
Research registration unique identifying number (UIN)
Not applicable.
Guarantor
Sushan Ghimire and Salina Subedi.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Data availability statement
All relevant data supporting the findings of this case report are included within the article. No additional data are available.
Patient’s perspective
The patient was informed postoperatively that a rare anatomical variation of the gallbladder was discovered during surgery. She reported that she had not experienced any unexpected symptoms after surgery and was relieved to know that the procedure had been completed safely and that the finding did not affect her recovery. The patient stated, “I was surprised to learn about the unusual position of my gallbladder, but I am glad the doctors were able to manage it safely and that my recovery was smooth.”
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All relevant data supporting the findings of this case report are included within the article. No additional data are available.