Laparoscopic management of a case of accessory gall bladder with review of literature.

Gall bladder duplication is a rare congenital anomaly. True duplication is still rarer. Pre-operative detection helps in avoiding complications or missing the gall bladder during surgery. Ultrasonography (USG) and magnetic resonance cholangiography are investigation of choice. Laparoscopic cholecystectomy is the preferred modality for management of double gall bladder. We present a case diagnosed as cholelithiasis on USG. While doing laparoscopic surgery 2 gall bladders were found. She had a normal gall bladder that was lying in the supraduodenal area. It had cystic duct that joined the common bile duct. There was an accessory gall bladder attached to the anterior free margin of the liver. This gallbladder was occluded with a big solitary calculus occupying the whole of gall bladder cavity and had a small feeding vessel; whereas its duct had fibrosed.

INTRODUCTION

Duplication of gall bladder is a rarity, incidence being 1:4000 of the autopsies.[1] Occurs due to division of gall bladder primordium in the 5th–6th embryonic week. A true double/accessory gall bladder develops due to the formation of an extra gall bladder primordium.[1] In case of true duplication, both gall bladder may have a common or different cystic duct and also blood supply. Differential diagnosis of gall bladder duplication includes Phrygian cap deformity, gall bladder diverticulum, choledochal cyst, focal adenomyomatosis, folded gall bladder, pericholecystic fluid and intraperitoneal fibrous band. Preoperative diagnosis helps in preventing any complications during laparoscopic cholecystectomy.[2]

CASE REPORT

A 61-year-old female having recurrent attacks of pain (grade 7/10) admitted to emergency. Abdominal examination revealed tenderness in epigastrium and right hypochondrium. A diagnosis of recurrent acute cholecystitis cause cholelithiasis was made based on ultrasonography (USG) and patient prepared for surgery. Nothing remarkable was noted in other investigations. Magnetic resonance (MR) and cholangiography/endoscopic retrograde cholangiopancreatography were not done. In routine cases of cholelithiasis our policy is to go by USG alone if no pathology in biliary duct system is suspected.

After insertion of ports, one gall bladder like structure was found hanging from the free edge of liver [Figure 1]; its thin pedicle entered the liver substance. Pedicle consisted of a thin artery and a fibrous band. The portal and supraduodenal area were explored. Gall bladder, cystic duct and Calot's Triangle were defined, and cystic duct followed by cystic artery was clipped and gall bladder extracted out. It contained solitary calculus.

Figure 1

The four main types of gall bladder duplication. Top left: Double gall bladder with a Y-shaped cystic duct entering the common bile duct. Top right: Double gall bladder with independent cystic duct entering the common bile duct. Bottom left: The second gall bladder is connected by its own cystic duct in the left hepatic duct. Bottom right: The cystic duct of the duplicated gall bladder enters the right lobe of the liver to connect with the right hepatic duct (Classification of accessory gall bladder by Philippe Jeanty)

The pedicle of accessory gall bladder was ligated, and it was extracted out. It has a big solitary calculus. Both the gall bladders were labelled and sent for histopathology examination [Figure 2].

Figure 2

Case photograph. Accessory gall bladder is seen hanging from the free edge of liver; normal gall bladder at 8 - 9 ‘O’ clock position.

DISCUSSION

Boyden[1] was first to classify gall bladder duplication in 1926 into 2 broad groups:

Vesical fellea divisa or bilobed gall bladder – this has one cystic duct.

Vesical fellea duplex – here the two gall bladders have 2 cystic ducts; it is further divided into 2 types. Y type where both cystic ducts fuse and then join the common bile duct. In the H type, both cystic ducts join the common bile duct separately.

Another classification was given by Gross RE, who divided duplication of gall bladder into 6 subtypes. Harlaftis et al.[2] divided gall bladder duplication into 2 main groups:

Type 1 split primordial gall bladders classified as septate, V type and Y type

Type 2 Accessory gall bladders divided as H type, ductular and trabecular type.

Jeanty and Sutter[3] have divided gall bladder duplication into 4 main types:

Double gall bladder with a Y-shaped cystic duct entering the common bile duct

Double gall bladder with independent cystic duct entering the common bile duct

The second gall bladder is connected by its own cystic duct in the left hepatic duct

The cystic duct of the duplicated gall bladder enters the right lobe of the liver to connect with the right hepatic duct.

Figure 1 (illustration) with permission from ‘the fetus. net’.

Our case falls into type 4 of the classification given by Philippe Jeanty and also H type ductular in Harlaftis and Vesica fellea duplex H-shaped as per Boyden's classification. The accessory gall bladder occurs adjacent to normal gall bladder in the gall bladder fossa, intrahepatic, subhepatic or with in the gastrohepatic ligament. In our case, gall bladder was hanging freely from the margin of segment V of the liver.

USG and MR cholangiography remain the most used diagnostic methods; none of the modalities are 100% sensitive. It is often found incidentally during surgery for cholelithiasis.[4]

In the English literature, more than 200 cases of duplication of gall bladder have been reported. The author could find a total of 30 cases of gallbladder duplication published that were managed laparoscopically. First time cholecystectomy for double gall bladder was done by James Sherren. Mir Yasir et al., Sadf Ali et al. have reported cases of duplication of gall bladder that were diagnosed during laparoscopic cholecystectomy. Vijayraghavan and Belagavi.[5] Reported a case of true accessory/actual duplication of gall bladder where the cystic duct had obliterated and had no communication with biliary tree. Various other authors have published cases of gall bladder duplication that were managed laparoscopically.

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Conflicts of interest

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