Journal of Medical Evidence

CASE REPORT
Year
: 2020  |  Volume : 1  |  Issue : 1  |  Page : 35--37

Symptomatic duplicated gall bladder – A rare presentation with a review of the literature


Amit Gupta1, Bhargav Gajula1, Jaydeep Jain1, Jyoti Sharma1, Udit Chauhan2, Ravi Kant3,  
1 Department of Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Radiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
3 All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Correspondence Address:
Dr. Amit Gupta
Department of Surgery, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
India

Abstract

Gallbladder duplication is a rare congenital anomaly. Knowledge of its various types is important since it can complicate cholecystectomy. Many varieties of gall bladder duplication and its classification are reported in the literature. Pre-operative diagnosis plays a crucial role in the planning of surgery and preventing possible injuries or re-operation if the accessory gallbladder has been overlooked during the initial surgery. Gallbladder duplication though rare requires special attention to pre-operative anatomy and its variation. The operative challenge is more than the usual laparoscopic cholecystectomy and should be done by fundus first approach by an experienced laparoscopic surgeon. We report a case of a 44-year-old -male who presented with biliary colic. His pre-operative imaging confirmed the diagnosis of the duplicated gall bladder, and he underwent successful laparoscopic cholecystectomy.



How to cite this article:
Gupta A, Gajula B, Jain J, Sharma J, Chauhan U, Kant R. Symptomatic duplicated gall bladder – A rare presentation with a review of the literature.J Med Evid 2020;1:35-37


How to cite this URL:
Gupta A, Gajula B, Jain J, Sharma J, Chauhan U, Kant R. Symptomatic duplicated gall bladder – A rare presentation with a review of the literature. J Med Evid [serial online] 2020 [cited 2022 Sep 30 ];1:35-37
Available from: http://www.journaljme.org/text.asp?2020/1/1/35/290141


Full Text



 Introduction



The biliary system is well known for its anatomical variations. The duplication of the gall bladder is described since ancient Roman time, but little is known about its embryology that how multiple gall bladder develops. Boyden was the first to classify gall bladder anomalies and more such variations have been added to the literature.[1] Duplicate gall bladder has to be considered when an additional cystic structure is seen in the right upper quadrant during ultrasonography screening for a gall bladder disease. The presence of double gall bladder is a relatively benign condition, but there is an increased prevalence of gall stone disease and cystic duct obstruction, causing biliary colic to life-threatening cholangitis.[2] Congenital anomalies and anatomic variations are predisposing factors for intra-operative iatrogenic injuries. Hence, knowledge of exact anatomy and this congenital anomaly is necessary to avoid complications and multiple surgeries.[3] Multiple variations of the gall bladder and its management are evolving, but surgery remains the mainstay for symptomatic gall bladder disease. However, open versus laparoscopic surgery in the context of unfamiliar anatomy still arises. Hence, we report our experience of successful laparoscopic double cholecystectomy, which is feasible in expert hands with a pre-operative road map to aberrant anatomy. We also review current literature with emphasis on classification systems and management options.

 Case Report



A 44-year-old man presented to surgery outpatient department with chief complaints of colicky pain in the right upper abdomen for 2½ months. The pain was intermittent and associated with the intake of fatty food. There was no history of fever or jaundice. On clinical examination, the abdomen was soft, non-tender and no lump was palpable. Routine blood investigations were within the normal limits. Ultrasound abdomen reported a distended gall bladder with gall stone and similar gall bladder-like structure adjacent to it with corresponding cystic duct. Differential diagnosis of the septate or duplicate gall bladder was made. The patient underwent magnetic resonance cholangiopancreatography (MRCP) which confirmed complete duplication of gall bladder with multiple gall stones largest of size 26 × 20 in one of it, having two separate cystic ducts opening into the biliary duct with liver abscess of 2.6 cm × 2.7 cm × 3.6 cm in segment II and IVa [Figure 1]. Liver abscess was managed with medical therapy and the patient was planned for laparoscopic double cholecystectomy. Diagnostic laparoscopy was essentially unremarkable; no other anomaly was found in the abdomen. Intraoperatively two fused gall bladder were present upper one was distended with bile, lower one was distended with bile and calculi, having separate cystic ducts running parallel, which drained into the bile duct and cystic arteries arising from right hepatic artery [Figure 2]. A standard four-port laparoscopic cholecystectomy with fundus first approach was performed. The principles of the critical view of safety were followed. Post-operative recovery was uneventful and got discharged on POD 1 in satisfactory condition. Pathology reported as septate gall bladder with two cystic ducts and gall bladder lined by columnar epithelium with features of chronic cholecystitis [Figure 3]. No evidence of malignancy was found in the specimen.{Figure 1}{Figure 2}{Figure 3}

 Discussion



Gall bladder duplication is a rare congenital anomaly with a prevalence of 1 in 4000.[1] Duplication occurs during the 5th or early 6th weeks of embryonic life, during which a single primordium bifurcates. The type of duplication is determined by time of bifurcation, i.e., the earlier the bifurcation, the more complete the degree of duplication. However, the origin of accessory gall bladder from either or both the hepatic ducts remain unexplainable.

The most important differential for accessory gall bladder is Type 2 choledochal cyst arising from the right hepatic duct. It needs special attention, as the patient requires close follow-up in latter case because of its potential for the development of malignancy. It is highly difficult to demarcate between the two by pre-operative MRCP. Laparoscopy can be helpful in delineating anatomy, defining final diagnosis and aids in the treatment in the form of resection at the same. However, definitive diagnosis is made out only by post-operative histopathology, wherein duplicate gall bladder has muscular wall with an epithelial lining.[4] There are many classification systems for gall blabber duplication described in the literature. Boyden classified it into 'Vesica fellea divisum' (bilobed gall bladder that has one cystic duct) and 'Vesica fellea du-plex' (true gall bladder duplication). The latter is further subdivided into Y shaped type (duplication of whole gall bladder with the two cystic ducts uniting before entering the CBD) and H shape or ductular type (the two cystic ducts entering separating into the biliary tree).

In 1926, Boyden classified them into six types (a-f) as follows

Septate gallbladderFundic duplicationBody duplication with the single cystic ductDuplication of whole gall bladder with the two cystic ducts uniting before entering the CBD (Y Shaped)Complete type or ductular type, the two cystic ducts entering separating into the biliary tree (H type)Bilateral gall bladder.

In 1977, Harlaftis organised these duplications into two types based on morphology and embryogenesis. It was later modified with the addition of left trabecular variant to Type 2 duplication. An accessory gall bladder branching from both the left and right hepatic ducts and even a triple gall bladder were reported.[5]

Most recently, unified classification has been proposed by Causey et al., by adding Type 3 (combined type), wherein both the Type 1 and 2 features are present.[6]

The literature supports laparoscopic double cholecystectomy for Type 1, but advocates open surgery for Type 2 because of the increased theoretical risk of injury to the common bile duct and the right hepatic artery owing to its high insertion of second cystic duct and need of extensive dissection.[7] This case was Type 3 duplication (septate gall bladder with duplicated cystic ducts consistent with Causey report and a laparoscopic intervention is feasible with meticulous and safe dissection of fundus first approach in light of pre-operative imaging anatomy.

 Conclusion



Duplication of the gall bladder, though rare in the presentation, one must be aware of its variations. There are no specific symptoms attributed to the double gall bladder. It can be identified on ultrasonography for symptomatic gall stone disease with the presence of cystic structure adjacent to the gall bladder. Pre-operative MRCP is the choice of investigation to delineate variable anatomy to avoid undue surprise during surgery. If available, intra-operative cholangiogram or imaging with indocyanine green can avoid inadvertent injury to a great extent.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Boyden EA. The accessory gall-bladder-an embryological and comparative study of aberrant biliary vesicles occurring in man and the domestic mammals. Am J Anat 1926;38:177-231.
2Vezakis A, Pantiora E, Giannoulopoulos D, Fontara S, Kontis E, Polydorou A, et al. A duplicated gallbladder in a patient presenting with acute cholangitis. A case study and a literature review. Ann Hepatol 2019;18:240-5.
3Borghi F, Giraudo G, Geretto P, Ghezzo L. Perforation of missed double gallbladder after primary laparoscopic cholecystectomy: Endoscopic and laparoscopic management. J Laparoendosc Adv Surg Tech A 2008;18:429-31.
4Bhojwani R, Jain N, Mishra S. Laparoscopic evaluation and resection of type-II choledochal cyst arising from right hepatic duct mimicking gall bladder duplication. J Minim Access Surg 2019;15:158-60.
5Nanthakumaran S, King PM, Sinclair TS. Laparoscopic excision of a triple gallbladder. Surg Endosc 2003;17:1323.
6Causey MW, Miller S, Fernelius CA, Burgess JR, Brown TA, Newton C. Gallbladder duplication: Evaluation, treatment, and classification. J Pediatr Surg 2010;45:443-6.
7Kim RD, Zendejas I, Velopulos C, Fujita S, Magliocca JF, Kayler LK, et al. Duplicate gallbladder arising from the left hepatic duct: Report of a case. Surg Today 2009;39:536-9.