Patrick R Reardon, MD, Amanda Parker, MD, Michele A Riordon, MD, Vadim Sherman, MD, Brian J Dunkin, MD. The Methodist Hospital Department of Surgery; Methodist Institute for Technology, Innovation, and Education Houston, Texas 77030
Introduction: Sinistroposition of the gallbladder (SPG), is a very rare anatomic variant. Between September of 2005 and June of 2009 we unexpectedly encountered three such cases. We report on these cases treated by laparoscopic cholecystectomy (LC). All cases were performed utilizing the fundus-down technique.
Methods: A retrospective review of 1556 consecutive cases in a database revealed 3 cases of SPG. Clinical data queried included operative time (OT), estimated blood loss (EBL), length of stay (LOS), port size and position, and intraoperative and postoperative complications. The cases were all initiated with a midline, supraumbilical, 2 mm port, as is our standard. A 10 mm port (or 5 mm port) was then placed at the umbilicus. Viewing through a 30º laparoscope via the umbilical port, the left-sided position of the gallbladder was noted. Once this anatomic variant was noted, a 2 mm left subcostal port was then placed, in a mirror image fashion to a standard LC port placement. Inspection of the area of the cystic duct revealed that the ductal anatomy was obscured by the gallbladder as it crossed over to the right side. The cholecystectomy was then completed in a fundus-down fashion.
Results: None of the cases was diagnosed preoperatively. There was one male patient, age 63 and two female patients, both aged 47. Mean values, ± standard deviation, were: OT = 87.0 ± 20.42 min; EBL = 33.3 ± 14.4 ml; LOS = 0.0 ± 0 days. One case required conversion of a 2 mm port to a 5 mm port because of a thickened gallbladder and one case required conversion of a 2 mm port to a 3 mm port due to a thickened gallbladder. The cystic duct entered the common bile duct on the right side in all patients. The cystic artery appeared to arise on the right side in all patients. The pathologic diagnosis in two patients was: cholelithiasis and chronic cholecystitis. In the third patient, the diagnosis was cholelithiaisis, cholecystitis, and hydrops of the gallbladder. There were no intraoperative complications or complications within 30 days. The incidence of SPG in this series of 1556 consecutive cases of LC was 0.19%.
Conclusion: Sinistroposition (SPG), is a very rare anatomic variant. The gallbladder is attached to segment III of the liver and crosses the common hepatic duct from left to right, obscuring the cystic duct insertion. The fundus-down technique allows the gallbladder to be mobilized and rotated to the right, exposing the cystic duct for safe completion of the operation. When this rare anatomic variation is encountered it can be safely treated laparoscopically and with the use of 2 mm instrumentation. The authors recommend using a fundus-down technique to improve visualization of the cystic duct junction with the common bile duct, increasing the safety of the operation. Particular attention should be paid to the posterior aspect of the dissection of the gallbladder bed as it crosses, from left to right, just anterior to the common hepatic duct and porta hepatis in order to avoid potential major complications.
Session Number: SS19 – Videos: HPB (Hepatobiliary and Pancreas)
Program Number: V035
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