Laparoscopic choledochoscopy for choledocholithiasis is possible in the anatomical anomaly of left gallbladder

Abstract

Laparoscopic cholecystectomy (LC) is more challenging in the anatomical variation of left-sided gallbladder with the anomaly also highly related to biliary anomalies. Therefore, there has been a reluctance to operate close to the common bile duct (CBD) in left gallbladder patients, and thus choledocholithiasis is usually treated with endoscopic retrograde cholangiopancreatography (ERCP). There is emerging evidence that single stage LC and CBD exploration for choledocholithiasis may be superior to two stage LC and ERCP in terms of short-term and long-term morbidity, cost and length of stay. With the re-emergence of laparoscopic choledochoscopy, the purpose of this case report is to demonstrate the feasibility of this approach for choledocholithiasis.

Background

Single stage laparoscopic cholecystectomy (LC) and common bile duct (CBD) exploration is an acceptable management for choledocholithiasis, with theoretical and demonstrable advantages over two stage LC and endoscopic retrograde cholangiopancreatography (ERCP). Surgeons may be perceived this to be challenging in anomalous hepatobiliary and vascular anatomy, as in the anatomical variation of left-sided gallbladder.^1–3 We report a female patient who presented to the emergency department with worsening right upper quadrant pain and obstructive jaundice. Here, we discuss the safe management of this patient with single stage LC and CBD exploration via choledochoscopy through the cystic duct.

Case presentation

A woman in her mid-20s presented to the hospital with worsening right upper quadrant pain and vomiting. On examination, her vital signs were normal, the abdomen was tender in the right upper quadrant, and she had a positive Murphy’s sign.

Investigations

Liver function tests revealed an elevated serum bilirubin of 45 umol/L, alkaline phosphatase 142 U/L, gamma glutamyl transpeptidase 171 U/L, alanine transferase 602 U/L, aspartate transaminase 588 U/L, white cell count 3.9 x10^∧9/L and C reactive protein 7 mg/L. An abdominal ultrasound showed cholelithiasis with mild gallbladder wall thickening. No stone was seen in the CBD, which was normal in size. The intrahepatic ducts were normal. The radiological diagnosis was that of acute cholecystitis; however, there was no mention of a left-sided gallbladder.

Treatment

The patient was admitted for an urgent cholecystectomy, in accordance with current recommendations for grade 2 cholecystitis. For the procedure, a standard four port American style LC was performed with the patient in the supine position. A left-sided gallbladder was identified (figure 1). Meticulous dissection was done to expose the Calot triangle contents. To prevent the injury to a potentially anomalous bile duct, the dissection was performed close to the gallbladder wall until the critical view of safety was identified by a blunt dissection of the upper part of Calot’s space. There were no arterial or biliary anomalies identified and were, therefore, considered to be ideal for a safe dissection.

Figure 1.

Retracted left gall bladder with omental adhesion.

An intraoperative cholangiogram showed a type A intrahepatic biliary confluence as per the Blumgart classification.⁴ No abnormal biliary anatomy was identified apart from the left-sided gallbladder and the cystic duct entering the common hepatic duct from the right side. A solitary stone was visualised in the distal CBD, just above the ampulla (figure 2). The decision was made to proceed with CBD exploration using a 5 mm choledochoscope (Olympus Australia, Notting Hill, Australia) via the cystic duct.

Figure 2.

Intraoperative cholangiogram showing filling defect in common bile duct.

The choledochoscopy setup included the video stack on the patient’s left and the surgeon on the right. An assistant retracted Hartmann’s pouch with an instrument inserted in the epigastric port with the gallbladder fundus retracted through the far right port. The choledochoscope was inserted through the right upper quadrant working port and directed into the cystic duct. Choledochoscopy confirmed the presence of a single stone which was engaged with a 1.7Fr Nitinol extractor basket (Cook Medical, Bloomington, USA), however, on engagement the stone fragmented with stone fragments then pushed through the ampulla. A repeat intraoperative cholangiogram confirmed a clear CBD (figure 3).

Figure 3.

Intraoperative cholangiogram showing contrast in duodenum.

Outcome and follow-up

The patient was discharged home on the first postoperative day. The histopathological findings of the specimen demonstrated chronic calculous cholecystitis. The patient was reviewed 1 week postoperatively and the liver functions were within normal values including a serum bilirubin of 9 umol/L. The patient had returned to normal activities when reviewed at a clinic appointment at 4 weeks.

Discussion

Left-sided gallbladder is a rare congenital anomaly with a reported prevalence that ranges from 0.04% to 1.1%. It was first described by Hochstetter in 1886.⁵ Left-sided gallbladder is defined as a gallbladder to the left of the falciform ligament and attached to the under surface of segment 3 without situs inversus viscerum.⁶ It is usually an incidental intraoperative finding and is associated with variations in hepatobiliary vascular anatomy.⁷

CBD obstruction may be suspected during the preoperative workup including abdominal ultrasound, which may show findings of intrahepatic duct dilatation, CBD dilatation or a CBD stone. In this case, CBD obstruction was suspected only from the clinical presentation and biochemical results, with the ultrasound failing to detect suspicious features suggesting CBD stones or even detecting the left-sided gallbladder. This is not unusual, however, with ultrasound be reported to have a low positive predictive value (2.7%) for detecting left-sided gallbladder.⁸

There is debate regarding the management of choledocholithiasis. One option is to perform a single stage treatment via LC and intraoperative cholangiogram followed by CBD exploration to clear the duct during the same operation. Another option is to perform preoperative MRCP then ERCP to clear the CBD, followed by LC.

However, ERCP is associated with short-term and long-term complications. There is an increasing evidence that managing CBD stones laparoscopically is safe and at a minimum, decreases hospital stay and is economically superior.^{9 10} Bile duct stone clearance rate by a laparoscopic approach has been reported to be as high as 90%.¹¹ One previous case of CBD exploration for the treatment of choledocholithiasis in left-sided gallbladder has been described, but by utilising a fifth laparoscopic port and by retracting the falciform ligament via a suture to the abdominal wall. In the current case, CBD exploration was able to be performed using the same four ports used for the cholecystectomy, demonstrating the safety and applicability of the procedure without requiring a different setup and thus achievable by all laparoscopic surgeons.¹² In our centre, we treat CBD stones primarily with intraoperative cholangiogram and single stage CBD exploration. We do not generally perform MRCP prior to operation, even in cases with suspected CBD stones such as this case where a bilirubin of 45 preoperatively would raise suspicion for choledocholithiasis.

The incidence of CBD injury at cholecystectomy for left-sided gallbladder is reported to be as high as 4.4%.¹³ However, this may incorporate data from the early era of LC, where the CBD injury rate was higher. The skills and training of surgeons in the art of laparoscopy and endoscopy are far superior to what it was 20–30 years ago, and the surgeons of today are far better equipped to perform laparoscopic choledochoscopy. The continuous improvement of digital imaging technology and miniaturisation have contributed to improving visualisation and hence feasible extraction of bile duct stones. Thus, in conclusion, we anticipate management of cases such as this one will become more commonplace with time.

Learning points.

• Left-sided gallbladder (LSGB) is a rare condition.

• Preoperative ultrasound has a low positive predictive value for detecting LSGB (2.7%).

• LSGB is often first encountered at surgery.

• Common bile duct (CBD) exploration should be attempted for stone extraction in LSGB.

• Endoscopic retrograde cholangiopancreatography and sphincterotomy should be reserved for cases of failure of CBD exploration.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).