Look, but to the left: A rare case of gallbladder sinistroposition and comprehensive literature review

Abstract

Left-sided gallbladder (LSGB) is a rare anatomic variation that, while benign in the context of its transposition, is of significant intraoperative importance. Due to its association with other anatomic anomalies involving key structures in the hepatobiliary system, discovering it intraoperatively as opposed to preoperatively suddenly increases the difficulty of a gallbladder procedure.

Full text

Annals of Medicine and Surgery 71 (2021) 103016
Available online 1 November 2021
2049-0801/© 2021 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
Case Report
Look, but to the left: A rare case of gallbladder sinistroposition and
comprehensive literature review
Talal Almas
a
,
*
, Muhammad Faisal Murad
b
, Eyad Mansour
a
, Muhammad Kashif Khan
b
,
Muneeb Ullah
b
, Faisal Nadeem
b
, Adil Sha
b
, Tarek Khedro
a
, Mohammad Almuhaileej
a
,
Abdulaziz Abdulhadi
a
, Abdulaziz Alshamlan
a
, Vikneswaran Raj Nagarajan
a
, Emad Mansoor
c
a
Royal College of Surgeons in Ireland, Dublin, Ireland
b
Department of Surgery, Maroof International Hospital, Islamabad, Pakistan
c
Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
ARTICLE INFO
Keywords:
Gallbladder
Sinistroposition
ABSTRACT
Left-sided gallbladder (LSGB) is a rare anatomic variation that, while benign in the context of its transposition, is
of signicant intraoperative importance. Due to its association with other anatomic anomalies involving key
structures in the hepatobiliary system, discovering it intraoperatively as opposed to preoperatively suddenly
increases the difculty of a gallbladder procedure.
1. Introduction
Sinistroposition gallbladder or a left-sided gallbladder (LSGB) is a
seldom anatomic aberration in which the gallbladder is located below
the left lobe of the liver [1]. This anatomical aberration can be divided
into three different anatomical abnormalities, including situs visceral
inversus, right left-sided gallbladder, and true left-sided gallbladder [2].
Left-sided gallbladder (LSGB) is a term that describes an abnormally
situated gallbladder, which exists in three different forms. The rst form
is a gallbladder that is located at the left upper quadrant of the abdomen
as part of situs viscerus invertus (SVI); the entire content of the abdomen
is situated in a mirrored position of the normal anatomical position. A
LSGB that is not part of SVI is subcategorized into a true left sided
gallbladder and a right sided gallbladder with abnormally located lig-
amentum teres. The former is located under segment III of the liver, to
the left of ligamentum teres and the falciform ligament. The latter is
considered a left sided gallbladder due to ligamentum teres abnormal
translocation to the right side and is located under segment IVb of the
liver [2].
The majority of the cases reported are correlated with a right-sided
falciform ligament and are also known as a false left-sided gallbladder
[3,4]. If the falciform ligament was not on the right side, it is known as a
true-sided gallbladder, which is incredibly rare [4].
In 1886, Hochstetter was the rst to describe the LSGB without situs
viscerum inversus [5]. Ever since it was discovered, its prevalence has
remained low, ranging between 0.04% and 1.1% [6]. In this case, the
LSG is a solitary nding, in that the remaining viscera maintain their
ordinary anatomical location.
Gallbladder diseases typically prompt urgent surgical intervention
[7], which is when most cases of LSGB are in fact diagnosed. Moreover,
it is usually associated with anatomical variation, including biliary tract
anomaly, portal vein anomaly, liver segment IV atrophy, or alteration in
the hepatobiliary anatomy [1]. This variation unfortunately confers a
higher risk of bile tract injury during the surgery, requiring more deli-
cate and careful operation [8].
Therefore, it is crucial to suspect the anomaly prior to the operation
in order to prevent devastating injuries to the vascular and biliary
structures. The unintentional ligation of the bile duct and left branch of
the portal vein, for example, may compromise three-quarters of the liver
blood supply, consequently leading to liver failure, biliary congestion,
and eventually biliary leakage [9].
In our case, we report a rare nding of a left-sided gallbladder
located underneath the left lobe of the liver and to the left of the falci-
form ligament with no other remarkable abnormalities. Consent was
obtained from the patient prior to the writeup of the present case report.
The current study has been reported in accordance with the SCARE
criteria [9].
* Corresponding author. Royal College of Surgeons in Ireland, 123 St. Stephen’s Green, Dublin, Ireland.
E-mail address: Talalalmas.almas@gmail.com (T. Almas).
Contents lists available at ScienceDirect
Annals of Medicine and Surgery
journal homepage: www.elsevier.com/locate/amsu
https://doi.org/10.1016/j.amsu.2021.103016
Received 14 October 2021; Received in revised form 31 October 2021; Accepted 31 October 2021

Annals of Medicine and Surgery 71 (2021) 103016
2
2. Case presentation
A 33-year-old married female presented to us with right hypochon-
drium pain radiating to both shoulders and back associated with nausea
for the last 5 months. She noticed the episodes were increasingly dis-
tressing whenever she consumed fatty food. No comorbid conditions
were present. General physical and systemic examination were
unremarkable.
Her complete blood count and liver function tests were within
normal limits. Abdominal ultrasound, however, presented multiple
gallstones with no pericholecystic uid, no gallbladder wall thickness
and a normal calibre common bile duct (Fig. 1 and Fig. 2). However, this
information was insufcient to conclude whether the gallbladder was an
anatomic variant. It was only during the operative course that the
aberrant anatomic location of the gallbladder was discovered.
She was planned for elective laparoscopic cholecystectomy. She
tested positive for COVID-19 prior to surgery, and therefore the patient
was deferred for surgery. Three weeks later, when the patient tested
negative, she was admitted, and laparoscopic cholecystectomy was
performed.
Per-operative ndings after diagnostic laparoscopy showed a variant
anatomy with the gallbladder located underneath left lobe of liver just
below and to the left of falciform ligament (Figs. 3–5).The patient was
discharged within 24 hours, and the recovery time was unremarkable.
Fig. 1. Right upper quadraxnt ultrasound showing multiple calculi.
Fig. 2. Left: Gallbladder replete with gallstones. Right: Common bile duct with normal calibre and morphology.
Fig. 3. Intraoperative image divulging a left-sided gallbladder.
Fig. 4. Port sites were modied for better and safer progress for surgery.
T. Almas et al.

Annals of Medicine and Surgery 71 (2021) 103016
3
3. Discussion
The gallbladder is a hollow organ that is responsible for the pro-
duction and storage of bile and bile salts, and it is normally located in the
right upper quadrant of the abdomen. Anatomically, the gallbladder lies
beneath the liver segments IV and V and has an inferior peritoneal
surface [10]. In most people, the gallbladder is located to the right of the
falciform ligament, whereas in 0.04%–1.1% it is abnormally located to
the left side [11].
Embryologically, three main processes explain the development of
LSGB without SVI. The rst process involves normal embryological
development of the cholecystic bud from the hepatic diverticulum. The
bud then migrates to the left side and becomes situated under the liver.
The second processes describe the development of a gallbladder on each
side of ligamentum teres. The left sided gallbladder persists while the
right sided gallbladder gradually atrophies and disappears [12]. As
stated in categorisation of LSGB, the development can be attributed to
the abnormal location of ligamentum teres in the right side.
Inammation of the gallbladder, cholecystitis, classically presents
with right upper quadrant abdominal pain, nausea, vomiting, and fever;
with the pain may also radiate to the right shoulder and/or the back, as
seen in our patient [13]. The malposition of the gallbladder to the left
side does not affect the neural supply or the innervation as the central
nervous system does not transpose. Therefore, gallbladder disease such
as cholecystitis presents with typical signs and symptoms in 75% of
patients with LSGB [14,15]. This, in addition to the fact that LSGB is
rarely diagnosed by preoperative ultrasonography alone, most of the
cases are only diagnosed intraoperatively. While ultrasonography falls
short for LSGB, other imaging modalities such as magnetic resonance
cholangiography and computerized tomography cholangiography are
benecial in detailing the anatomy and conrming a LSGB [14,16]. In
practice, other ndings can raise the suspicion of LSGB, including
abnormal intrahepatic portal vein branching or an absent liver segment
IV [8]. Furthermore, other anatomical variations in the hepatobiliary,
Fig. 5. Intraoperative image demonstrating cystic artery and cystic duct.
Table 1
MR =magnetic resonance. US =ultrasound. CT =computed tomography. TB =tuberculosis.
Age
and
sex
Patient characteristics Radiological ndings Surgical treatment Intraoperative ndings
Saafan et al.
2
26 F Recurrent RUQ colicky
pain, nausea, vomiting for
2 months, history of PCOS
US Abd: contracted gallbladder with large 1.8
cm stones. MRI Abd: gallbladder located left
of ligamentum teres hepatis inferior to
segment III
Laparoscopic
cholecystectomy with
four-port technique
LSGB diagnosed
Nagendram
et al.
8
35 F RUQ pain for 2–3 months
post-vaginal birth
US Abd: gallstones Laparoscopic
cholecystectomy
Gallbladder against left lobe of liver
between segments III and IV, left of
falciform ligament. Cystic duct was
narrowed
Colovic et al.
17
42 F 8-year history of
intermittent epigastric
pain
– Open surgery for
symptomatic liver cyst
LSGB incidentally diagnosed
intraoperatively; attached to inferior
surface of left lateral hepatic segment to the
left of the round ligament
Colovic et al.
17
70 F 15-year history of
recurrent biliary colic
US Abd: gallbladder stone and liver cyst Open surgery LSGB incidentally diagnosed
intraoperatively; cystic duct anatomy was
normal, joining the common bile duct from
the right side
Pereira et al.
18
56 M Biliary colic MR cholangiopancreatography: gallbladder
left of falciform ligament and cystic duct
entering common hepatic duct
Laparoscopic
cholecystectomy
LSGB diagnosed
Hirohata et al.
23
86 M Acute upper abdominal
pain
CT Abd: gallbladder centrally dislocated, wall
enhancement discontinued. MRI Abd:
gallbladder thickened and swollen
Laparoscopic
cholecystectomy with
exible and optimal port
site
LSGB diagnosed, round ligament attached
to right side of gallbladder
Printes et al.
24
60 M Admitted with severe
RUQ pain, hypertensive,
history of pleural TB and
biliary lithiasis
US Abd: suggestive of biliary lithiasis Laparoscopic
cholecystectomy and
umbilical herniorrhaphy
LSGB diagnosed, found in left hepatic lobe,
with thin walls and stones
Di Bella et al.
25
72 F Admitted due to acute
cholecystitic
– Open surgery from
initial explorative
laparoscopy
LSGB diagnosed during explorative
laparoscopy
Roli et al.
26
76 F Admitted due to acute
cholecystitis
– Laparoscopic
cholecystectomy
LSGB diagnosed during laparoscopy
Nguyen et al.
27
49 F Admitted due to
intermittent RUQ pain for
3 days
US Abd: cholelithiasis without dilatation of
the bile ducts
Laparoscopic
cholecystectomy
LSGB diagnosed during laparoscopy, cystic
duct joined the common hepatic duct on the
right side, and the cystic artery crossed
anterior to the common bile duct in a right-
to-left direction
Zoulamoglou
et al.
28
31 M 6-month history of colicky
RUQ pain that progressed
over 3 days and radiated
to right ank
US Abd: gallstone about 18 mm in diameter Laparoscopic
cholecystectomy
LSGB diagnosed during laparoscopic
cholecystectomy; attached to inferior
hepatic segment III and left of the round
ligament
T. Almas et al.

Annals of Medicine and Surgery 71 (2021) 103016
4
gastrointestinal, and the genitourinary system have been associated
with LSGB, with those of the hepatobiliary system being more common.
These variations include an underdeveloped or a duplicated common
biliary duct, infra-portal bile duct, and pancreatic anomalies like
annular pancreas and dorsal pancreas agenesis [15,17]. Gastrointestinal
anomalies include duodenal malrotation and polysplenia whereas the
genitourinary anomalies include intrapelvic ectopic testes [17].
Although laparoscopic cholecystectomy of a LSGB is safe, it is asso-
ciated with higher risk of complications such as common bile duct injury
[18,19]. Therefore, surgeons are advised to have a more careful
approach by limiting diathermy use as well as careful division of
structures to avoid potential intraoperative injury [16]. Some studies
even recommend additional measures such as the use of intraoperative
cholangiogram as it might be useful in verifying the biliary tract anat-
omy [20]. Modifying the laparoscopic port sites is also suggested by
some studies to improve surgical outcomes and to minimise the risk of
potential complications [20,21]. In order to better study the underlying
anatomical aberration, we conducted a comprehensive literature search.
The results obtained are delineated by Table 1 below [22–29].
4. Conclusion
Laparoscopic cholecystectomy is a generally safe procedure, even in
the rare case of a LSGB. Most cases of a LSGB are diagnosed intra-
operatively, and this sudden discovery during the procedure can in-
crease the difculty, duration, and stress of the procedure due to the
other potential anatomic anomalies that LSGB is associated with in the
hepatobiliary system. Therefore, the identication of the LSGB should
ideally be done preoperatively, a strategy that is also hindered by a few
key factors: it is an extremely rare anatomic anomaly, it does not present
with any characteristic clinical signs or symptoms, and it is not easily
identiable on ultrasonography’s relatively low-resolution. Surgeons
should be aware of the techniques that can be utilized intraoperatively
in order to minimize the risk of complications and improve patient
outcomes.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Sources of funding
N/A.
Ethical approval
N/A.
Consent
Written informed consent was obtained from the patient for publi-
cation of this case report and accompanying images. A copy of the
written consent is available for review by the Editor-in-Chief of this
journal on request.
Disclosures
N/A.
Declaration of competing interest
N/A.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.amsu.2021.103016.
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