Laparoscopic management of 'Y-shaped' gallbladder duplication with review of literature.

Gallbladder duplication is a rare congenital malformation that occurs in about 1:4000 cases. Congenital anomalies of the gallbladder and anatomical variations of their position are associated with an increased risk of complications during laparoscopic cholecystectomy. We report a case of gallbladder duplication with symptomatic cholelithiasis, who presented with recurrent episodes of biliary colic and subsequently underwent laparoscopic cholecystectomy with intraoperative cholangiography. We also discussed in brief about the available literature support in relation to incidence of this disorder, imaging modalities used, intraoperative strategies and recommended measures for safe outcomes.

INTRODUCTION

Congenital anomalies of the gallbladder and anatomical variations of the biliary tract are important as they are associated with an increased risk of complications during laparoscopic as well as open cholecystectomy. Although other anomalies are common, duplication of gall bladder is rare, which is reported to occur in about 1:4000 births.[1] Role of pre-operative and intraoperative imaging is helpful for better delineation of the anatomy and to minimise potential injury. We hereby present a case of duplicated gall bladder in terms of its evaluation and management.[2]

CASE REPORT

This 28-year-old male presented to us with recurrent episodes of biliary colic, which was aggravated by fatty meal. The last episode was 2 weeks back which subsided with conservative treatment. He had no history of any co-morbidity. On examination, the abdomen was soft, non-tender without any mass or organomegaly. Routine blood reports including liver function tests were normal. Abdominal ultrasound was suggestive of gallbladder duplet with multiple calculi. Magnetic resonance cholangiopancreatography (MRCP) confirmed duplex gall bladder with two different cystic ducts joining to form common Y channel draining into common duct [Figure 1]. He was taken up for laparoscopic cholecystectomy under general anaesthesia. Intraoperatively, initial assessment revealed single intrahepatic gall bladder with a duct and cystic artery [Figure 2]. Intraoperative cholangiogram was performed for better identification of anatomy. Duct and artery were clipped and divided separately [Figure 3]. Dissection of the specimen revealed the presence of double gall bladder with two separate cystic ducts joining to form a common cystic duct [Figure 4]. On opening the specimen, one lobe had multiple small calculi while the other lobe had none. Post-operative period was uneventful; he was discharged the next day. Histopathology report confirmed the findings with chronic inflammatory changes.

Figure 1

Magnetic resonance cholangiopancreatography image showing two lobes of gall bladder joining to form single cystic duct and then inserting into bile duct

Figure 2

Laparoscopic image appearing as intrahepatic single gall bladder

Figure 3

Laparoscopically dissected Calot's triangle with single cystic duct

Figure 4

Specimen of gall bladder with two lobes

DISCUSSION

Duplication of gall bladder is a relatively rare congenital anomaly of the biliary tract that is reported to occur in about 1:4000 births.[1] However, the exact incidence of this anomaly in general population cannot be accurately assessed as the reported cases represent only those who presented with symptoms or were encountered as incidental finding during surgery, imaging studies or at autopsy.[3] Duplication of gall bladder is proposed to be due to exuberant budding of the developing biliary tree when the caudal bud of the hepatic diverticulum divides. Anatomic variants of gallbladder duplication are classified by Boyden's as follows[1] vesica fellea divisa (bilobed or bifid gall bladder, double gall bladder with a common neck),[3] vesica fellea duplex (double gall bladder with two cystic ducts) (i) Y-shaped type (the two cystic ducts uniting before entering the common bile duct) (ii) H-shaped type (ductular type, the two cystic ducts entering separately into the biliary tree). Differential diagnosis includes gallbladder diverticula, gallbladder fold, Phrygian cap, choledochal cyst, pericholecystic fluid, focal adenomyomatosis and intraperitoneal fibrous bands.[3]

Duplication of gall bladder does not present with any specific symptom but is usually associated with the development of cholelithiasis, which may be due to inadequate bile drainage. Stones disease mostly occurs in one lobe, but both lobes can also be involved.[4] Duplication is also seen to be associated with other congenital anomalies, such as an anomalous right hepatic artery.[3] The presence of anomalous biliary system constitutes one of the most important predisposing factors for iatrogenic bile duct injuries during cholecystectomy, especially during laparoscopic approach.[2] Hence, a good quality pre-operative imaging of biliary tree becomes important for avoiding iatrogenic injuries in these patients.[5] Ultrasonography (USG) is generally the first imaging modality used in patients with suspected biliary disease. Although USG findings may suspect an anomalous biliary system with diagnosis of stones, the precise details of cystic duct, common duct and vascular anatomy are not possible. MRCP is considered to be a standard, non-invasive imaging technique for the evaluation of patients with suspected anomalies of the biliary apparatus.[5]

Combining intraoperative cholangiography with laparoscopic cholecystectomy is an appropriate strategy to minimise the risks of inadvertent injury to the biliary system.[3] It is mandatory to dissect the hepatocystic triangle meticulously to obtain the critical view. In symptomatic patients, simultaneous removal of both the lobes of gall bladder is recommended during surgery even if the disease is present only in one lobe, to avoid cholecystitis and biliary colic in the remaining viscus.[4]

With reporting this case, authors would like to highlight the presentation, imaging and management of a rare disorder which can have potential implications during one of the most commonly performed laparoscopic procedures today that is cholecystectomy, if not diagnosed pre-operatively. It is also suggested to incorporate intraoperative cholangiography during cholecystectomy for better delineation of biliary tree anatomy for prevention and/or early diagnosis of catastrophic vasculo-biliary complications.

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Conflicts of interest

There are no conflicts of interest.