Andres E Giovannetti, MD1, Michael Prendergast, MD2. 1UIC-MGH General Surgery Residency, 2Presence St Francis Hospital Evanston
INTRODUCTION: Biliary anatomy is variable and its knowledge is key in the surgical management of our patients. Gallbladder duplication is a rare finding with an incidence estimated of 1:4,000 cases. Was first described in a Roman Emperor’s slave autopsy. Management requires proper preoperative and/or intraoperative biliary structures identification to avoid major injuries. When diagnosed preoperatively, MRCP has been the test of choice but in the majority of cases, the diagnose is intraoperatively where cholangiogram and fluorescent cholangiography using intravenous indocyanine green (ICG) become key in the management of this anatomic variations.
METHODS: We presented a 24 y.o. female with no medical history, presenting to the office with a history of intermittent severe right upper quadrant (RUQ) pain for the last 6 months, exacerbated with the ingestion of fatty meals and associated with nausea and emesis. Symptoms required several visits to the emergency department. RUQ ultrasound was performed and showed cholelithiasis without cholecystitis. She was scheduled for elective laparoscopic cholecystectomy.
Surgery started in the usual fashion, ICG was administered, trocars placed and abdomen was explored. At the beginning of the surgery, we had the impression of dealing with a large and folded gallbladder and with omental adhesions. We started the dissection and the cystic artery was identified, clipped and transected. Using ICG imaging we identify a tubular structure connecting two gallbladders with the common bile duct. A plane was found between both gallbladders and careful dissection was done to separate them. A “Y shape” tubular structure was completely dissected that represented two independent cystic ducts that joined together to form a common cystic duct that finally drains to the common bile duct. An intraoperative cholangiogram was performed with confirmation of the biliary anatomy. After proper identification of the structures, the common cystic duct was clipped and transected and the gallbladder dissected from the liver bed without complications. The specimen was examined and two separated gallbladders were identified, both with stones inside. Surgery was tolerated well and patient clinical progress was uneventful.
CONCLUSION: Gallbladder duplication is a rare biliary anatomic variation. MRCP is the study of choice if suspected preoperatively. Anatomic variations in biliary structures can lead to severe injuries and complications. Intraoperative cholangiogram and ICG technology is a helpful tool, especially during complex cases. To the best of our knowledge, this is the first case of gallbladder duplication diagnosed and managed using ICG.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87481
Program Number: V005
Presentation Session: Biliary Session
Presentation Type: Video