Christopher F McNicoll, MD, MPH, MS1, Minh-Tri N Pham, MD1, Hasanali Z Khashwji, MD1, Charles R St. Hill, MD, MSc, FACS1, Nathan I Ozobia, MD, FACS2. 1UNLV School of Medicine, 2University Medical Center of Southern Nevada
Gallbladder anatomy is highly variable, and surgeons must be prepared to identify anomalies of form, number, and position. Variants include gallbladder agenesis, diverticulum, duplication, bilobed, multiseptate, Phrygian cap, ectopic, and hourglass gallbladder. The hourglass gallbladder has been described from the earliest days of cholecystectomy, as Morton described a congenital case in 1908, and Else thoroughly described the acquired and congenital strictures leading to the hourglass deformity in 1914. We describe a case of an hourglass gallbladder found during one-step endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy.
This 71 year old male presented to an outside hospital with one day of nausea, and constant, severe, epigastric pain that radiated to his back. He endorsed a history of similar pain several times in the past. His abdomen was soft, nontender, and without Murphy sign. Laboratory evaluation revealed total bilirubin 2.0 mg/dL, alkaline phosphatase 195 U/L, AST 835 U/L, ALT 800 U/L, and no leukocytosis. CT abdomen and pelvis revealed cholelithiasis, distal choledocholithiasis, intra- and extra-hepatic ductal dilation, and a 3.8 centimeter left liver hemangioma. He was transferred for management of choledocholithiasis, and an abdominal ultrasound revealed cholelithiasis, without gallbladder wall thickening or pericholecystic fluid, and a 7.7 millimeter common bile duct without choledocholithiasis. He was taken to the operating room for a one-step ERCP and laparoscopic cholecystectomy. Upon laparoscopy, dense adhesions to the gallbladder were found. After initially attempting to obtain the critical view of safety, we then embarked on the retrograde “top down” dissection. This isolated a spherical structure measuring 2.4 x 2.2 centimeters. Two very thin tubular structures were identified, clipped, and transected after we found they were too small to place a cholangiocatheter. The common bile duct appeared to be pulled anteriorly by surrounding inflammation, though this was later found to be the proximal segment of gallbladder. The intra-operative ERCP identified a remnant gallbladder with cholelithiasis and no extravasation of contrast. Given the unusual anatomy, we completed the operation, ordered a post-operative CT liver and MRCP, and consulted a hepatopancreatobiliary surgeon. A small remnant gallbladder was identified on CT liver, though not on MRCP. Completion laparoscopic cholecystectomy with intraoperative cholangiogram and ultrasound was performed on hospital day 4.
This hourglass gallbladder variant likely occurred secondary to chronic fibrosis from cholecystitis, leading to a proximal and distal gallbladder lumen. In anatomic uncertainty, the “top down” dissection, intraoperative cholangiography, CT liver, and expert consultation are safe methods to avoid iatrogenic injury.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87339
Program Number: P135
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster