Surgical approach to a left-sided gallbladder

Abstract

Biliary colic is a pain in the right upper quadrant or epigastrium thought to be caused by functional gallbladder spasm from a temporary obstructing stone in the gallbladder neck, cystic duct or common bile duct. A 56-year-old man presented with frequent episodes of typical biliary colic. At initial laparoscopy, the gallbladder was absent from its anatomic location. Further inspection revealed a left-sided gallbladder (LSGB), suspended from liver segment 3. Preoperative ultrasound, the most common imaging modality for symptomatic gallstones, has a low positive predictive value for detecting LSGB (2.7%). Laparoscopic cholecystectomy (LC) was delayed to attain additional imaging. A magnetic resonance cholangiopancreatography demonstrated the gallbladder left of the falciform ligament with the cystic duct entering the common hepatic duct from the left. The patient underwent an elective LC 8 weeks later. The critical view of safety is paramount to safe surgical dissection and could be safely achieved for LSGB.

Background

Biliary colic is a pain in the right upper quadrant or epigastrium thought to be caused by functional gallbladder spasm from a temporary obstructing stone in the gallbladder neck, cystic duct or common bile duct (CBD).^1–3 As many as one-third of patients with gallstones will develop symptoms of biliary colic over a 10-year period.⁴ Once an episode of biliary colic has occurred, the incidence of repeated attacks is reported to be as high as 50% per year.⁵ Although referred to as biliary colic, the pain is constant in nature and usually last several hours.^1–3

A left-sided gallbladder (LSGB) is a rare biliary anomaly generally reported in patients having cholecystectomy for symptomatic gallstones.⁶ Laparoscopic cholecystectomy (LC) is the gold standard treatment for symptomatic gallstones.⁷ In patients with LSGB, LC is associated with a higher incidence of bile duct injury (4.4%), necessitating the establishment of a safe surgical approach in these patients.⁶

Case presentation

A 56-year-old man presented with frequent episodes of typical biliary colic with associated nausea and anorexia. He had a surgical history of open appendicectomy; however, there were no significant medical comorbidities. On examination, he was afebrile with normal vital signs. He had central obesity (body mass index=38) and a mildly tender epigastrium but no evidence of peritonism. The white cell count and liver function tests were within normal range. An abdominal ultrasound revealed numerous gallbladder calculi and mild gallbladder wall thickening; however, there was no pericholecystic fluid or CBD dilatation. There were no comments suggesting variation of the gallbladder from its orthotopic position. Due to the frequent episodes of biliary colic, an LC was organised for the following day.

First Operation: Following general anaesthesia and prophylactic antibiotics, routine ports were inserted at the umbilicus (10 mm), epigastrium (10 mm), right mid-axillary (5 mm) and mid clavicular (5 mm) lines. At the laparoscopic exploration, the gallbladder was absent from its normal location. Further inspection revealed an LSGB, suspended from the medial part of liver segment 3 (figure 1), with the falciform and round ligaments in the normal position. The cardiac diaphragmatic pulsation was on the left side and the rest of abdominal viscera appeared normally positioned. In light of aberrant anatomy and potential risk of injury to variant biliary tree or vascular structures, the attending surgeon decided to delay performing a cholecystectomy and the operation was abandoned prior to any dissection being performed.

Figure 1.

Left-sided gallbladder—suspended from liver segment 3 medially.

The operative findings were discussed with the patient who was discharged the following day on a course of oral antibiotics. A magnetic resonance cholangiopancreatography (MRCP) was arranged, which demonstrated the gallbladder to the left of the falciform ligament with the cystic duct entering the common hepatic duct from the left side (figure 2). A large stone was seen in Hartmann’s pouch. No other aberrant biliary or vascular anatomy was identified. The patient was advised that a weight reduction of 5 kg may reduce the liver size to facilitate vision and mobilisation of the liver during subsequent operation.

Figure 2.

Transverse magnetic resonance cholangiopancreatography. Gallbladder left of round ligament. LSGB, left - sided gallbladder.

Second Operation: The patient underwent an elective LC 8 weeks later, during which time the patient lost 7 kg. Following general anaesthesia and prophylactic antibiotics, five laparoscopic ports were used (see table 1 and figure 3).

Table 1.

Laparoscopic port site, size and function

Port site	Port size (mm)	Function
Right subcostal ant. Axillary line	5	1. Working port—fundus mobilisation 2. 15 Fr. Drain
Right midclavicular line	5	Working port—Hartmann’s mobilisation
Infra-umbilical	10	Camera port
Left midclavicular line	5	Working port—electrocautery
Left subcostal ant. Axillary line	10	1. Direct access—initial camera 2. Falciform lift

Figure 3.

Modified laparoscopic port site placement. (1) Working port for fundus mobilisation, (2) working port for Hartmann’s pouch mobilisation, (3) camera port, (4) working port for electrocautery, (5) direct access initial camera entry and falciform lift.

The liver had reduced in size and was more pliable, facilitating retraction and exposure. The falciform ligament was divided and elevated to aid exposure of the gallbladder and liver (figure 4). The gallbladder fundus was retracted towards the left shoulder. The distal gallbladder was then dissected off the cystic plate and then continued down on the gallbladder wall towards the cystic artery and duct. After a challenging tedious dissection, the cystic artery and duct were identified after the critical view of safety was obtained. The short cystic artery was isolated, clipped and divided. The cystic duct was then clipped and an intraoperative cholangiogram was attempted but not achieved due to a very narrow cystic duct. The cystic duct was then clipped and divided. Antegrade dissection of the gallbladder off segment 3 performed. The gallbladder was placed in a retrieval bag and extracted through port 1 (see figure 3). A 15 French gauge, low-pressure suction drain was placed in the gallbladder bed.

Figure 4.

After performing a falciform lift, the toothed grasper is used to retract gallbladder fundus towards the patient’s left shoulder.

Outcome and follow-up

The patient’s postoperative course was uneventful. There was no bile stained fluid in the drain, which was removed day postoperation. Liver function tests days 1 and 2 postoperation were unremarkable. The patient was discharged on day 2 tolerating a normal diet and without pain. At outpatient review 2 weeks later, he was well with no symptoms of clinical concern.

Discussion

In 1886, Hochstetter first described a small series of LSGB and subsequently, the accepted definition is a gallbladder left of the round ligament, attached to the undersurface of segment 3 without situs inversus viscerum.^{6 8} This rare anatomical variation of the extra-hepatic biliary anatomy is most frequently reported in patients having cholecystectomy for symptomatic gallstones.⁶

As described in our present case, LSGB is frequently overlooked on preoperative ultrasound, the most common imaging modality for symptomatic gallstone disease.⁶ The positive predictive value of ultrasound-detected LSGB is a mere 2.7%.⁶ Most patients with symptomatic gallstones do not require other forms of cross-sectional imaging (CT or MRI), which have a higher detection rate for LSGB and thus the aberrant anatomy is generally encountered unexpectedly at the time of surgery as we have reported.⁶

When an LSGB is encountered at surgery, the attending surgeon is faced with options of: (1) proceeding laparoscopically with the adjuncts of additionally placed ports or manoeuvres of the falciform ligament, (2) seeking advice from an experienced general or hepatobiliary surgeon who may provide intraoperative assistance or (3) delaying the procedure to obtain additional imaging to define to biliary anatomy.⁶

In the case described, the patient underwent additional preoperative imaging with MRCP demonstrating a gallbladder the left of the falciform ligament with the cystic duct entering the common hepatic duct from the left side. It was useful to identify the path of the cystic duct and exclude other biliary variations. At subsequent operations, modified port placement was utilised (see table 1 and figure 3). An additional left subcostal port in the anterior axillary line performed the falciform lift, improving exposure of the subhepatic space (see figure 4). A left midclavicular port facilitated ergonomic electrocautery dissection.

The incidence of CBD injury at cholecystectomy for LSGB is reported to be 4.4%, much higher than 0.3% for orthotopically positioned gallbladders.⁹ The aforementioned techniques aid only in exposure of the gallbladder; however, the key to safe dissection is the technique used.⁶ Our reported case uses the principles of dissection described by Connor et al to achieve the critical view of safety.^{10 11}

Learning points.

• Preoperative ultrasound, the most common imaging modality for symptomatic gallstone disease, has a low positive predictive value for detecting left-sided gallbladder (LSGB) (2.7%). Thus, an LSGB is often first encountered at surgery.

• Preoperative imaging such as magnetic resonance cholangiopancreatography may define the path of the cystic duct and exclude other biliary variations.

• The critical view of safety is paramount to safe surgical dissection at cholecystectomy. This view can be safely achieved for LSGB.