Laparoscopic Cholecystectomy for Acute Abdomen Due to Torsion of Gallbladder Successfully Diagnosed Preoperatively – A Single Center Experience

Hidejiro Urakami, MD, PhD, Hiroto Kikuchi, MD, Yuichi Nishihara, MD, Yoshiki Kawaguchi, MD, Jo Tokuyama, MD, PhD, Koji Osumi, MD, Shiko Seki, MD, PhD, Atsushi Shimada, MD, Takashi Oishi, MD, PhD, Yo Isobe, MD, PhD, Sumio Matsumoto, MD, PhD. National Hospital Organization Tokyo Medical Center

Introduction: Torsion of gallbladder (GT) is a rare entity that brings a diagnostic challenge preoperatively to both surgeons and radiologists. It is known to occur when there is rotation of the gallbladder along the axis of the cystic duct and the vascular pedicle. GT typically presents as an acute abdomen requiring emergency surgery, however, preoperative diagnosis is difficult.

Cases: Five hundred and twenty seven laparoscopic cholecystectomy was done in our hospital since 2009 to 2014. We experienced three cases (0.6%) of GT successfully diagnosed preoperatively during this period. ‹Case 1› A 88-year-old male visited our hospital for intermittent abdominal pain continuing for one week. Slight abdominal tenderness and Murphy’s sign were detected and blood test showed slight elevation of CRP with no abnormality of liver function tests. MDCT and ultrasound demonstrated a markedly enlarged gallbladder with a slightly thickened wall and an enhanced twisted cystic pedicle without stones, and diagnosed GT. In consideration of mild abdominal findings and slow onset, laparoscopic detorsion and cholecystectomy was done one day after emergency admission. The gallbladder was gangrenous and was rotated clockwise about 180 degrees at the cystic pedicle. Histological findings revealed massive necrosis and hemorrhage. ‹Case 2› A 78-year-old female was diagnosed acute cholecystitis due to gallbladder stones by family doctor and transferred to our hospital. Laboratory findings revealed elevated inflammatory reactions with normal liver function tests. Diagnosed GT by MDCT and ultrasound, and emergency laparoscopic cholecystectomy was done by reduced-port surgery. The gallbladder was rotated clockwise about 540 degrees. Histological findings revealed cholecystitis with hemorrhage. ‹Case 3› A 80-year-old female was treated conservatively for acute cholecystitis for 20 days at another hospital. The patient visited our hospital 5 days after discharge from another hospital due to recurrent abdominal pain. Body temperature was normal and blood test showed slightly elevated liver function tests with normal range of inflammatory reactions. Diagnosed GT by ultrasound, and emergency laparoscopic cholecystectomy was done. The gallbladder was gangrenous and was rotated clockwise about 180 degrees. Histological findings revealed chronic and acute cholecystitis. All the patients recovered without significant complications and discharged from our hospital 5 to 14 days following surgery.

Conclusion: We could successfully perform emergency laparoscopic cholecystectomy for all three GT cases diagnosed preoperatively by MDCT and / or ultrasound, however, some of these cases exhibited worrisome course preoperatively. Early diagnosis and immediate laparoscopic intervention can help to achieve a better patient outcome.