Large Gallbladder Removed by Laparoscopic Cholecystectomy A Case report

Abstract

Gallbladder stones impacted at neck of gallbladder can result in acute calculous cholecystitis with
mucocele gallbladder. Laparoscopic cholecystectomy is performed in such cases as an emergency
surgery. We present a case long gallbladder with mucocele formation that was managed by laparoscopic
approach. The gallbladder removed was 27.8cm in length. This is the longest gallbladder removed by
laparoscopic cholecystectomy in Pakistan so far. The patient had uneventful recovery.

Full text

J Islamabad Med Dental Coll 2023
1
Open Access
Large gallbladder Removed by Laparoscopic Cholecystectomy
A Case report
Muneeb Ullah1, Muhammad Faisal Murad2, Adil Shafi3, Aqsa Adeel4
1,4Assistant Consultant, General Surgery, Maroof International Hospital, Islamabad, Pakistan
2Chief of Surgery, Department of Surgery, Maroof International Hospital, Islamabad, Pakistan
3Registrar, Department of Surgery, General Surgery, Maroof International Hospital, Islamabad, Pakistan
A B S T R A CT
Correspondence:
Muneeb Ullah
Email: muneebullah@gmail.com
Article info:
Received: January 31, 2023
Accepted: March 30, 2023
Cite this article. Ullah M, Murad F M, Shafi A, Adeel A. Long gallbladder Removed by
Laparoscopic Cholecystectomy A Case report. J Islamabad Med Dental Coll. 2023; 12(1):
Funding Source: Nil
Conflict of Interest: Nil
https://doi.org/10.35787/jimdc.v12i1.946
Introdu ct i on
Diseases of gallbladder have a wide spectrum that
includes asymptomatic gallstones, biliary colic,
cholecystitis, mucocele, empyema gallbladder,
gangrene, perforation, peritonitis, polyps and
malignancy.1 The definitive treatment warrants
surgical intervention in the form of laparoscopic or
open cholecystectomy.2 One of the emergency
presentations is acute calculous cholecystitis which,
if associated with gallstone impacted at neck, would
require emergency surgery.3 This impaction can also
result in over-distended mucocele gallbladder or
empyema gallbladder. Laparoscopic
cholecystectomy is performed in routine, for such
patients with aim to minimize the trauma without
compromising the efficacy of the treatment. It also
leads to lesser pain, shorter hospital stay and early
return to routine activity.4 We present a case of
overdistended huge mucocele of gallbladder
secondary to acute calculous cholecystitis
successfully managed by laparoscopic
cholecystectomy at Maroof International Hospital,
Islamabad.
Case Pr es en t ation
Our patient was a 45 years old female who
presented with pain in right upper quadrant of
abdomen with nausea for the last six days. It was
sudden and started after she had a pizza with cheese
topping. There was no vomiting, anorexia or fever.
The pain remained constant with bouts in between
and some decrease in intensity with oral analgesics.
There was no pruritis, discoloration of eyes, dark
urine or clay-colored stools. She initially went to a
general physician who then referred the patient to
us. On examination, the patient had tender right
Gallbladder stones impacted at neck of gallbladder can result in acute calculous cholecystitis with
mucocele gallbladder. Laparoscopic cholecystectomy is performed in such cases as an emergency
surgery. We present a case long gallbladder with mucocele formation that was managed by laparoscopic
approach. The gallbladder removed was 27.8cm in length. This is the longest gallbladder removed by
laparoscopic cholecystectomy in Pakistan so far. The patient had uneventful recovery.
CASE REPOR T

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hypochondrium with positive murphy’s sign and a
palpable gallbladder. While the liver function tests
were normal, the hepatobiliary ultrasound reported
a solitary 12mm stone impacted in the neck of
overdistended gallbladder as well as increased
gallbladder wall thickness of 4.5mm. The patient was
planned for laparoscopic cholecystectomy in acute
calculous cholecystitis. Standard four ports were
used. Diagnostic laparoscopy revealed acutely
inflamed overdistended gallbladder (Figure 1 and 2).
Figure 1: Peroperative image of gallbladder
Figure 2: Peroperative image of gallbladder
Gallbladder contents were aspirated using
aspiration needle that revealed mucocele
gallbladder. Afterwards laparoscopic
cholecystectomy was completed. The size of
gallbladder (postoperative) was 27.8cm (Figure 3)
Figure 3: Postoperative image of Gallbladder
Patient was discharged the next day. Follow up
consultations revealed uneventful recovery.
Discuss io n
Gallbladder is situated on the undersurface of
segment IV and V of liver and has a peritoneal
attachment to liver.5 The critical knowledge of
anatomy, its variations and clinical experience is
necessary for a safe and uneventful surgery.3 The
gallbladder is a pear shaped organ with an average
length of 4.5 to11.6 cm and capacity of 30 to 50ml.6
Acute calculous cholecystitis is accompanied by
inflammation of gallbladder that presents as a
combination of right upper quadrant pain that may
radiate to the back or right shoulder, nausea,
vomiting and fever.7 In cases where the gallbladder
stone is impacted at the neck of gallbladder, cystic
duct is blocked that results in the mucus
accumulation within the gallbladder. This leads to
over distended gallbladder i.e. mucocele.8
Prolonged obstruction of cystic duct leads to
continuous mucin secretion that ultimately over-
distends the gallbladder causing gallbladder wall
edema, dilation, inflammation, infection or
perforation. In patients with diabetes mellitus
especially who have poor control, there is
autonomic neuropathy and cholecystoparesis that
causes cholecystomegaly.6 In our case, stone
impacted at neck caused overdistension of
gallbladder. Mucocele itself is not an infective
pathology but if bacterial contamination occurs, it
can lead to empyema gallbladder.9 Empyema
gallbladder and mucocele are emergency
pathologies that require early intervention in the

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form of laparoscopic cholecystectomy unless there
is some definitive contraindication. The advantage
of laparoscopy in such cases is that, it yields minimal
scar, less pain and early mobilization. The huge sized
or overdistended gallbladders are attributed to
congenital anomalies, acquired or obstructive
causes as per literature review.10 Previously, in
Pakistan, the largest gallbladder removed via
laparoscopic cholecystectomy was 25.5cm at capital
hospital Islamabad as reported by Taj N et al. 6
Currently the largest gallbladder removed
laparoscopically by laparoscopic cholecystectomy is
30cm.3 In our case the length of the gallbladder was
27.8cm which is the longest documented gallbladder
removed laparoscopically so far in Pakistan to date.
This case report shows that apart from pathological
variation, laparoscopic cholecystectomy is still the
choice for operating acute or mucocele gallbladders.
Patient mobilizes early and is discharged as per
routine and large scars can be avoided.
Conclusion
Huge gallbladders, although difficult to handle but
can safely be removed via laparoscopic
cholecystectomy with good outcomes. A sound
knowledge of gallbladder anatomy, experience of
surgeon and good team are corner stones in such
surgeries.
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