Longest and left-sided gallbladder

Introduction: As laparoscopic cholecystectomy is one of the most common procedure done worldwide. Although anomalies are rare but are associated with congenital malformations of gallbladder, bile ducts and vascular system. Case Report: Herein, we present a case of young female presenting with symptoms of pain in right hypochondrium with ultrasonographic diagnosis of cholelithiasis undergone successful laparoscopic cholecystectomy with Intraoperative findings of: 1. The length of the gallbladder was measured to be 25.8 cm. 2. The fundus of the gallbladder was placed to the left of the falciform ligament. The gallbladder then extended to the right of the falciform ligament, reached up to the liver margin before taking a ‘U’-turn to lie in the usual gallbladder fossa. Conclusion: Anomalies of gallbladder present an important hurdle in successful laparoscopic cholecystectomy. Most of time not known preoperatively encountered during surgery. Isolated left-sided gallbladders are rare and found in 0.04–0.3% of cases. When there is question about anatomy of biliary tract intraoperatively one should consider for anomalies. A habit of calm and slow dissection with precautions should be developed. Clearance of the anatomical structures with limited use of electrocautery should be done before proceeding towards ligation or clip applications to structures. A surgeon should be well equipped with knowledge of anomalies of gallbladder and meticulous dissection with good exposure of structures should be done when an anomaly found. (This page in not part of the published article.) IJCRI – International Journal of Case Reports and Images, Vol. 5 No. 5, May 2014. ISSN – [0976-3198] IJCRI 2014;5(5):373–376. www.ijcasereportsandimages.com Mittal et al. 373 CASE rEport opEN ACCESS Longest and left-sided gallbladder Atul Kumar Mittal, Sourabh Sharma, Selva Kumar Balakrishnan, Jeevan Kankaria, Rajkamal Jenaw


IntrodUctIon
As laparoscopic cholecystectomy is one of the most common procedure done worldwide. Although anomalies are rare but are associated with congenital malformations of gallbladder, bile ducts and vascular system. Knowledge of anomalies before going for laparoscopic cholesystectomy is essential for safe and successful surgery. These can be dealt with meticulous dissection and appropriate identification of structures before applying clips and cutting structures. www.ijcasereportsandimages.com Mittal et al. 374

cAsE rEPort
We presents a case of young female presenting with symptoms of pain in right hypochondrium with ultrasonographic diagnosis of cholelithiasis. Laparoscopic cholecystectomy was planned. After creating pneumoperitoneum standart four ports were placed. On inspection of gallbladder findings noted were: 1. The fundus of the gallbladder was placed to the left of the falciform ligament. The gallbladder then extended to the right of the falciform ligament, reached up to the liver margin before taking a 'U'-turn to lie in the usual gallbladder fossa. The infundibulum and neck of the gallbladder were placed in the location of the normal gallbladder. The cystic duct entered the common hepatic duct from the right side, forming the Calot's triangle.
The surgery was completed laparoscopically in four hours, using the fundus-first approach ( Figure 1). The gallbladder was retrieved from the epigastric port (Figures 2 and 3). 2. The length of the gallbladder was measured to be 25.8 cm. The measurement was made in the operation theatre, using a transparent straight ruler with centimeter markings on one side and inch markings on the other side. Microscopy showed normal histology of the gallbladder ( Figure  4). Patient undergone uneventful laparoscopic cholecystectomy and was allowed oral intake in evening and discharged on next day. Patient followed for 30 days with no significant complaints.

dIscUssIon
Anomalies of gallbladder presents an important hurdle in successful laparoscopic cholecystectomy. Most of time not known preoperatively encountered during surgery. A prenatal study done by Bronshtein et al. 1993 on 10,016 fetal examinations after the 14th week of gestation reported 17 cases of anomalous gallbladder a 0.15% incidence of gallbladder malformations [1]. As per study of 500 subjects by Carbajo et al. Congenital gallbladder malformations were diagnosed in 1% of the cases, all cases were intraoperatively diagnosed and only two patient have to be converted to open cholecystectomy [2]. Isolated left-sided gallbladders are rare and found in 0.04%-0.3% of cases [3]. Two possible embryological etiologies for left-sided gallbladder are suggested.
1. Gallbladder is attached to the left lobe and migrates in front of common duct to come in left sidein which case the cystic duct is in a normal anatomic position. 2. Gallbladder is entirely formed from bud from the left side in which case the cystic duct joins the CBD or left hepatic duct from the left side [4,5].
As in our case gallbladder was of 25.8 cm which is largest as certified by Guinness book of world record with association of anomalous location of fundus of gallbladder to left side. Dr Naeem Taj operated a case at CDA hospital   When there is a question about anatomy of billiary tract intraoperatively one should consider for anomalies. There are four types of aberrant gallbladder: (1) intrahepatic, (2) left-sided, (3) transverse, and (4) retrodisplaced illustrated. The aberrant gallbladder produced false positive liver scans which were correctly diagnosed by hepatic angiography [6]. A habit of calm and slow dissection with precautions should be developed. Clearance of the anatomical structures with limited use of electrocautery should be done before proceeding towards ligation or clip applications to structures. An intraoperative cholangiography can be used to further delineate details of anatomy [7]. If surgeons' experience allow, one can proceed with laparoscopic surgery. Fundus first approach can make access easy in tricky situations. If surgeon is not experienced enough, conversion to open procedure should be done.

AN INTRODUCTION
Edorium Journals: On Web

About Edorium Journals
Edorium Journals is a publisher of high-quality, open access, international scholarly journals covering subjects in basic sciences and clinical specialties and subspecialties.

Edorium Journals: An introduction
Edorium Journals Team

But why should you publish with Edorium Journals?
In less than 10 words -we give you what no one does.

Vision of being the best
We have the vision of making our journals the best and the most authoritative journals in their respective specialties. We are working towards this goal every day of every week of every month of every year.

Exceptional services
We care for you, your work and your time. Our efficient, personalized and courteous services are a testimony to this.

Editorial Review
All manuscripts submitted to Edorium Journals undergo pre-processing review, first editorial review, peer review, second editorial review and finally third editorial review.

Peer Review
All manuscripts submitted to Edorium Journals undergo anonymous, double-blind, external peer review.

Early View version
Early View version of your manuscript will be published in the journal within 72 hours of final acceptance.

Manuscript status
From submission to publication of your article you will get regular updates (minimum six times) about status of your manuscripts directly in your email.

Mentored Review Articles (MRA)
Our academic program "Mentored Review Article" (MRA) gives you a unique opportunity to publish papers under mentorship of international faculty. These articles are published free of charges.

Most Favored Author program
Join this program and publish any number of articles free of charge for one to five years.

Favored Author program
One email is all it takes to become our favored author. You will not only get fee waivers but also get information and insights about scholarly publishing.

Institutional Membership program
Join our Institutional Memberships program and help scholars from your institute make their research accessible to all and save thousands of dollars in fees make their research accessible to all.

Our presence
We have some of the best designed publication formats. Our websites are very user friendly and enable you to do your work very easily with no hassle. Something more...
We request you to have a look at our website to know more about us and our services.
We welcome you to interact with us, share with us, join us and of course publish with us.

Invitation for article submission
We sincerely invite you to submit your valuable research for publication to Edorium Journals.

Six weeks
You will get first decision on your manuscript within six weeks (42 days) of submission. If we fail to honor this by even one day, we will publish your manuscript free of charge.

Four weeks
After we receive page proofs, your manuscript will be published in the journal within four weeks (31 days). If we fail to honor this by even one day, we will publish your manuscript free of charge and refund you the full article publication charges you paid for your manuscript.