Congenital agenesis of the gallbladder: An unpleasant surprise during laparoscopic cholecystectomy
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Congenital Agenesis of the Gallbladder: An Unpleasant Surprise During Laparoscopic Cholecystectomy Case Report V. Laopodis, L. Liasis, P. Stephanidis, D. Ntourakis, F. Kadjianis, P. Tzardis Received 24/07/2010 Accepted 27/09/2010
Abstract Background: Congenital gallbladder agenesis is a rare anomaly of the biliary tree. This asymptomatic situation is sometimes complicated with symptoms mimicking “gallbladder disease”. This case presentation shows the importance of a thorough preoperative investigation in order to avoid the increased risk of iatrogenic injury to the biliary tree. Case report: A 45-year old woman consulted her surgeon complaining of right upper quadrant pain, which was precipitated by fatty meals. After routine ultrasound investigation, she was scheduled for laparoscopic cholecystectomy. During the operation, there was no evidence of a gallbladder, even after thorough dissection of the porta hepatis. The procedure was terminated and postoperative MRCP confirmed the diagnosis of gallbladder absence. Conclusion: Gallbladder absence is a very rare congenital abnormality of the biliary tree. During laparoscopy, thorough dissection of Callot’s triangle increases the risk of iatrogenic injury. Preoperative advanced imaging studies are needed when routine investigation is equivocal.
Keywords
Gallbladder, Agenesis, Cholecystectomy, MRCP, Laparoscopic,
Introduction Congenital gallbladder agenesis is a very rare anomaly of the biliary tree. The incidence of congenital gallbladder agenesis is about 0,03% - 0,075% (autopsies by Talmadge [1], Kirshbaum [2], Smith et al). Most individuals remain asymptomatic for life. This abnormality was described in 1701 [3] and since 2003, 413 cases have been reported in the literature [4]. To date, more than 10 new cases have been reported [5-10]. Low clinical suspicion and frequent failure of routine investigation [11-14] to diagnose
1st Surgical Department, Hellenic Red Cross Hospital, Athens, Greece e-mail: [email protected]
gallbladder agenesis may lead to an unpleasant surprise during laparoscopy [15].
Methods A 45-year old woman consulted her surgeon, complaining of chronic epigastric and right upper quadrant pain. The pain occurred after eating and was precipitated by fatty meals. Clinical examination revealed a mild right upper quadrant tenderness. Blood investigations were within normal limits. Ultrasound examination showed a formation in the anatomical site of the gallbladder, which resembled a fibrotic and contracted gallbladder with internal opacity indicating gallbladder stones. Diagnosis of biliary colic was made and laparoscopic cholecystectomy was planned. During the laparoscopic procedure, the gallbladder could not be identified. Even after thorough dissection in the region of porta hepatis, no evidence of gallbladder, cystic duct or cystic artery was found. The operation was terminated at this stage since no further information could be obtained without an increased risk of biliary tree injury. During the 1st postoperative day, magnetic resonance ch
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