Laparoscopic cholecystectomy for Ectopic gall bladder

Laparoscopic cholecystectomy for Ectopic gall bladder

Ali I Yahya and Abdalkareem Ekleeb

Abstract

We report a rare case of ectopic gall bladder identified while performing laparoscopic cholecystectomy, the gall bladder being attached to left lobe of liver. It was removed successfully by laparoscopic cholecystectomy and the patient was discharged on first day with no bile duct injury.

Key words: left sided gall bladder, laparoscopic cholecystectomy

Introduction

The usual site of the gall bladder is attached to the right lobe of liver and on the right side of the CBD and falciform ligament. Some patients have situs inversus where the liver and gall bladder are on left side of the abdomen. One rare presentation, where the gall bladder is lying attached to the left lobe of the liver and left to the falciform ligament, has been reported in literature. In our institution one such case has presented amongst 3000 patients operated laparoscopically during an 8 year period.

Case report

A 28 years old female patient was admitted to the surgery department with symptoms of gall bladder stones. Ultrasound scans revealed that the patient had a gall bladder containing multiple stones with a normal GB wall. No comment was made on its position. Preoperative investigations were performed and she underwent Laparoscopic cholecystectomy, four ports were inserted first (11mm) at umbilicus, second (11mm) at xiphisterneum, 3rd (5mm) at right mid clavicular line below the costal margin, 4th (5mm) at right anterior axillary line. The gall bladder was not seen at the normal site but it was found below the left lobe of the liver on lesser curvature of the stomach attached to the left lobe of liver by its mesentery and lying left of the falciform ligament.

The Laparoscopic procedure and the findings are as following:

The fundus of the gall bladder grasped with the most right lateral port grasper. The left lobe of liver was rotated towards the right side due to traction of the gall bladder. There were adhesions between duodenum, GB and the liver which were released. Hartmans pouch was grasped by the surgeon's left hand grasper.

Dissection of the Hartman's pouch from the adhesions to the bile duct was performed and this dissection continued along the CBD untill the cystic duct was found. This was clipped and divided. The cystic artery was then found and clipped. The GB was removed. A drains was placed and removed next day. The patient was discharged on the first post operative day.

Discussion:

Abnormally positioned gall bladder to the left of the falciform ligament is a very rare anomaly and few cases were reported. In our patient this anomaly had not known detected by USS but only found during surgery. With the use of ultrasound, CT, MRI and ERCP the GB position can be detected preoperatively. We had was some diffculty in dissection but, had the diagnosis been known prior to surgery, the epigastric port could have been placed towards the left side to make the dissection easier. Special care needs to taken to identify the anatomy prior to division of any structures to prevent accidental injury to the CBD.

Conclusion:

Ectopic gall bladder where it lies to the left of the falciform ligament has not been seen in our surgery department before. When found, dissection should proceed with care to avoid damage to the bile duct . If the anatomy is in doubt then intra-operative cholangiogram should be performed.

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