Abstract
A 37-year-old man presented with epigastric pain, nausea, vomiting, and diarrhoea. Ultrasound demonstrated cholelithiasis with a stone impacted at the gallbladder neck. During laparoscopic cholecystectomy, the gallbladder was found to the left of the falciform ligament and was attached to an accessory liver lobe by a peritoneal fold containing vascular structures. Meticulous dissection and achievement of the critical view of safety allowed safe completion of the procedure without biliary or vascular injury. Postoperative magnetic resonance imaging with magnetic resonance cholangiopancreatography demonstrated a pedunculated accessory liver lobe arising from segment IV and a trifurcation-type portal vein anomaly without biliary obstruction. This case illustrates how coexisting congenital hepatobiliary and vascular variants can alter intraoperative orientation and highlights the importance of anatomy-based dissection when unexpected anatomy is encountered during laparoscopic cholecystectomy.
Introduction
Left-sided gallbladder is defined as a gallbladder located to the left of the falciform ligament in the absence of situs inversus and has a reported incidence of <1% [1, 2]. Accessory liver lobes are uncommon developmental anomalies and may be associated with aberrant vascular or biliary anatomy [5]. These variants may be undetected on routine preoperative imaging and can alter familiar surgical landmarks.
We report the intraoperative recognition and safe laparoscopic management of a left-sided gallbladder associated with an accessory liver lobe, with postoperative imaging characterization of associated portal venous anatomy.
Case report
A 37-year-old man with no significant medical or surgical history presented with a 2-day history of sudden-onset, non-radiating epigastric pain associated with nausea, vomiting, and diarrhoea. There was no fever, jaundice, or previous similar episode. He was afebrile and haemodynamically stable. Abdominal examination showed mild right upper quadrant tenderness with a negative Murphy sign. Complete blood count and liver function tests were within normal limits.
Abdominal ultrasound demonstrated a distended gallbladder measuring 9 × 3 cm with normal wall thickness, multiple gallstones, an 11-mm largest stone, a 7-mm stone impacted at the gallbladder neck, minimal biliary sludge, and no pericholecystic fluid.
The patient underwent laparoscopic cholecystectomy. The gallbladder was located to the left of the falciform ligament (Fig. 1). An accessory liver lobe was identified adjacent to the gallbladder bed, and the gallbladder was attached to this lobe by a peritoneal fold containing vascular structures (Fig. 2). Despite atypical orientation of the cystic duct and cystic artery, meticulous dissection allowed achievement of the critical view of safety. The cystic duct and artery were clipped and divided, and the gallbladder was removed without bile duct injury or significant bleeding (Fig. 3).
Intraoperative laparoscopic view showing the gallbladder located to the left of the falciform ligament.
Intraoperative view of the accessory liver lobe attached to the gallbladder via a peritoneal fold containing vascular structures.
Operative view after laparoscopic cholecystectomy showing the gallbladder bed and accessory liver lobe in situ.
Histopathological examination showed chronic cholecystitis with cholesterolosis.
Postoperative magnetic resonance imaging (MRI) of the abdomen with intravenous contrast and magnetic resonance cholangiopancreatography demonstrated a pedunculated accessory liver lobe measuring ~3.3 × 2.5 × 2.0 cm arising from the visceral surface of segment IV and extending into the umbilical fissure (Fig. 4). The portal vein was patent and demonstrated a trifurcation-type anomaly. There was no biliary obstruction.
MRI of the abdomen demonstrating a pedunculated accessory liver lobe arising from segment IV and extending into the umbilical fissure.
Discussion
Left-sided gallbladder is clinically important because associated biliary and vascular variants may increase the risk of iatrogenic injury during cholecystectomy [1–3]. Accessory liver lobes may contain vascular and biliary structures [5]. Their coexistence can distort usual operative orientation and obscure familiar landmarks.
In this case, the coexistence of a left-sided gallbladder, accessory liver lobe, and portal vein trifurcation provided a broader anatomical context than an isolated left-sided gallbladder. The combined anatomy altered intraoperative orientation, while careful dissection and strict adherence to the critical view of safety allowed safe completion of laparoscopic cholecystectomy [3, 4]. Postoperative imaging further characterized the accessory lobe and associated portal venous variation.
This is a single descriptive case and cannot establish prevalence, comparative operative risk, prognostic significance, or routine imaging recommendations. Its value is to support awareness of possible coexisting hepatobiliary and vascular variants and anatomy-based dissection when unexpected anatomy is encountered.
Conclusion
Unexpected combined hepatobiliary anatomical variants can alter orientation during laparoscopic cholecystectomy. In this case, meticulous dissection and achievement of the critical view of safety enabled safe management, and postoperative imaging characterized the associated accessory liver lobe and portal venous variation.
Conflicts of interest
None declared.
Funding
No external funding was received.
Ethics approval
Ethical approval for publication of this case report was obtained from the Institutional Review Board of King Abdulaziz Specialist Hospital, Taif, Saudi Arabia.
Patient consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
