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CASE REPORT
Year : 2014  |  Volume : 41  |  Issue : 1  |  Page : 45-46

Double gall bladder: A rare anomaly diagnosed during the laparoscopic cholecystectomy


1 Department of surgery, Sheri Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu & Kashmir, India
2 Department of surgery, Acharya Shri Chander College of Medical Sciences and Hospitals, Jammu, Jammu & Kashmir, India

Date of Web Publication7-Feb-2014

Correspondence Address:
Mir Yasir
Shah Faisal Colony, Upper Soura, Srinagar, Kashmir - 190 020
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.126754

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  Abstract 

Gall bladder duplication is an unusual biliary anomaly with a reported incidence of 1:4000 in the autopsy studies of humans. Lack of awareness, non-specific symptoms and signs and inadequacy of imaging methods are possible reasons for the reported problem of overlooking of the additional gall bladders before and during the surgery. We present a 22-year-old male who presented to us with a history of acute cholecystitis 3 months back with ultrasonography documented cholelithiasis. Laparoscopic cholecystectomy, which was carried out as an elective procedure, revealed a double gall bladder. An accurate, preferably pre-operative diagnosis, identification and removal of all gall bladders during the laparoscopy are mandatory to prevent inadvertent damage to the biliary ductal system, possible overlooking of the second gall bladder and hence post-operative cholecystitis.

Keywords: Biliary anomaly, double gall bladder, gall bladder duplication


How to cite this article:
Yasir M, Kapoor M, Aiman A, Suri A. Double gall bladder: A rare anomaly diagnosed during the laparoscopic cholecystectomy. J Sci Soc 2014;41:45-6

How to cite this URL:
Yasir M, Kapoor M, Aiman A, Suri A. Double gall bladder: A rare anomaly diagnosed during the laparoscopic cholecystectomy. J Sci Soc [serial online] 2014 [cited 2019 May 23];41:45-6. Available from: http://www.jscisociety.com/text.asp?2014/41/1/45/126754


  Introduction Top


Double gall bladder is a rare congenital anomaly with an incidence of 1 in 4000 patients. [1] It is important to diagnose this anomaly pre-operatively because the second gall bladder may be overlooked during surgery. [2]

Lack of awareness, non-specific symptoms and signs and inadequacy of imaging methods are possible reasons for the reported problem of overlooking of the additional gall bladders before and during surgery. [2] An accurate, preferably pre-operative diagnosis, identification and removal of all gall bladders during laparoscopy are mandatory to prevent inadvertent damage to the biliary ductal system and possible overlooking of the second or third gall bladder.


  Case Report Top


A 22-year-old Indo-Aryan male presented to us following history of acute cholecystitis 3 months back, which was diagnosed by ultrasonography (US) along with the presence of multiple calculi in gall bladder. At the time of his admission, he only had tender right hypochondrium, on deep palpation. There was no past history of jaundice. Repeat US of the patient revealed gall bladder stones with a normal gall bladder wall thickness. Hematological and liver function tests were within the normal limits. Patient was considered for laparoscopic cholecystectomy, which was carried out with the standard four port technique. Intra-operative findings revealed mild omental adhesions. Gall bladder was retracted in order to dissect the Calot's triangle. After the cystic duct and artery were clipped and cut, there was another gall bladder with its connection with the clipped cystic duct lying just beneath the liver bed. The vessel, which held the second gall bladder was clipped and cut. Both gall bladders were extracted from the epigastric port [Figure 1]. Post-operative period was uneventful.

Gross examination of the gall bladders showed two separate ducts from the two gall bladders uniting to form a single (common) cystic duct. Both gall bladders had a multiple mixed types of calculi.
Figure 1: Post-laparoscopic cholecystectomy specimen showing double gall bladder

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  Discussion Top


During the 5 th or early 6 th embryonic week, occasionally, the gall bladder primordium bifurcates and results in duplication of gall bladder. Although estimated to occur once in every 4,000 autopsies, the incidence of reported symptomatic cases is very low. [3] Duplication results from a split primordium whilst a true accessory gall bladder results from an extra primordium. It is difficult to tell whether our case represents a true accessory gall bladder or is an actual duplication. There are no specific symptoms or signs associated with the multiple gall bladders. Occasional case reports of post-cholecystectomy patients having a second attack of cholecystitis have been published.

Ultrasound, magnetic resonance cholangiopancreatography, computed tomography scan, scintigraphy and oral cholecystography have their limitations and are not 100% sensitive in identifying biliary ductal anomalies. The US appearance may be confused with choledochal cysts, gall bladder diverticulum, pericholecystic fluid collections, focal adenomyomatosis, Phrygian cap, extrinsic fibrous bands across the gall bladder and a folded gall bladder. [4]

Endoscopic retrograde cholangiopancreatography may be a useful adjunct, but may not be really indicated in every case of cholelithiasis or cholecystitis. Operative cholangiography or cholecystography, in suspected cases should help identify the additional structure.

Double gall bladders are classified according to the Boyden's classification. [1] The two main types of duplications are vesica fellea divisa or bilobed gall bladder and vesica fellea duplex or true duplication, with two different cystic ducts. The true duplication is sub-classified into Y shaped type (two cystic duct unites before entering into the common bile duct, usually the two gall bladder are adherent and occupy the same fossa) and the H shaped type or ductular type (two separate gall bladder and cystic ducts entering separately into the common bile duct).

The anatomical location of gall bladders can vary. Most gall bladders share a common peritoneal coat and are usually adjacent to each other. Occasionally, one gall bladder could be entirely intrahepatic or even sub-hepatic. True gall bladder duplications may share a common cystic duct, arterial supply or have separate cystic ducts and blood supply. [4],[5]

Careful appraisals of reported literature clearly emphasize the need for removal of accessory or duplicate gall bladders to prevent the surgical complications and repeated explorations, besides the embarrassment of diagnosing a patient with post-cholecystectomy cholecystitis. [6],[7],[8],[9],[10]

 
  References Top

1.Boyden EA. The accessory gallbladder, an embryological and comparative study of aberrant biliary vesicles occurring in man and domestic mammals. Am J Anesthesiol 1926;38:177-231.  Back to cited text no. 1
    
2.Mazziotti S, Minutoli F, Blandino A, Vinci S, Salamone I, Gaeta M. Gallbladder duplication: MR cholangiography demonstration. Abdom Imaging 2001;26:287-9.  Back to cited text no. 2
    
3.Cueto García J, Weber A, Serrano Berry F, Tanur Tatz B. Double gallbladder treated successfully by laparoscopy. J Laparoendosc Surg 1993;3:153-5.  Back to cited text no. 3
    
4.Horattas MC. Gallbladder duplication and laparoscopic management. J Laparoendosc Adv Surg Tech A 1998;8:231-5.  Back to cited text no. 4
    
5.Miyajima N, Yamakawa T, Varma A, Uno K, Ohtaki S, Kano N. Experience with laparoscopic double gallbladder removal. Surg Endosc 1995;9:63-6.  Back to cited text no. 5
    
6.Cummiskey RD, Champagne LP. Duplicate gallbladder during laparoscopic cholecystectomy. Surg Laparosc Endosc 1997;7:268-70.  Back to cited text no. 6
    
7.Ozmen V, Gorgun E, Unal ES, Polat C, Ozmen T. Laparoscopic treatment of a bilobed gallbladder: A case report and review of the literature. Surg Laparosc Endosc Percutan Tech 2003;13:345-7.  Back to cited text no. 7
    
8.Shirahane K, Yamaguchi K, Ogawa T, Shimizu S, Yokohata K, Mizumoto K, et al. Gallbladder duplication successfully removed laparoscopically using endoscopic nasobiliary tube. Surg Endosc 2003;17:1156.  Back to cited text no. 8
    
9.Goel A, Srivastava KN, Rana AK. Double gallbladder: A laparoscopic management. Surg Laparosc Endosc Percutan Tech 2003;13:348-9.  Back to cited text no. 9
    
10.Ohtani Y, Tobita K, Dowaki S, Sugio Y, Kashiwagi H, Tucker A. Duplicate gallbladder diagnosed with endoscopic retrograde cholangiopancreatography and treated with laparoscopic cholecystectomy. Dig Endosc 2003;15:69-71.  Back to cited text no. 10
    


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