Subtotal cholecystectomy as an approach to preventing injury in the left-sided gallbladder in the emergency surgery setting: A case study
A left-sided gallbladder is an unusual anatomic variation that makes gallbladder surgery challenging. Two systematic reviews on surgery for left-sided gallbladder highlighted high iatrogenic bile duct injury rates of 4.4% and 7.3%. This paper reports a female in her 40s with symptoms of acute calculous cholecystitis admitted to a secondary health-care center. After inserting four ports through standard sites for conventional gallbladder surgery, laparoscopic inspection revealed a phlegmonous left-sided gallbladder. No discordant situs of abdominal viscera was noted. Laparoscopic surgery was converted to open subtotal closed-tract cholecystectomy. No post-operative complications related to the surgical site were observed. A left-sided gallbladder affected by severe inflammation and infection is an extraordinary condition that should be considered as a risk factor. If an inflamed left-sided gallbladder is encountered, emergency subtotal cholecystectomy is an alternative to total cholecystectomy when the circumstances to adopt the strategies of a culture of safety in cholecystectomy for complete removal of the gallbladder are unfavorable.
Relevance for Patients: Subtotal cholecystectomy in patients with left-sided gallbladder reduces the risk for bile duct injuries, outweighing the potential side effects stemming from this surgical approach.
[1] Yoshida J, Chijiiwa K, Yamaguchi K, Yokohata K, Tanaka M. Practical Classification of the Branching Types of the Biliary Tree: An Analysis of 1,094 Consecutive Direct Cholangiograms. J Am Coll Surg 1996;182:37-40.
[2] Janssen BV, van Laarhoven S, Elshaer M, Cai H, Praseedom R, Wang T, et al. Comprehensive Classification of Anatomical Variants of the Main Biliary Ducts. Br J Surg 2021;108:458-62. doi: 10.1093/bjs/znaa147
[3] Banchini F, Capelli P. Left Side Gallbladder: Clinical and Anatomical Implication. Liver Pathology. London, UK: IntechOpen; 2021. doi: 10.5772/intechopen.92000
[4] Jung YK, Choi D, Lee KG. Laparoscopic Cholecystectomy for Left-Sided Gallbladder. Langenbecks Arch Surg 2022;407:207-12. doi: 10.1007/s00423-021-02263-0
[5] Pereira R, Singh T, Avramovic J, Baker S, Eslick GD, Cox MR. Left-sided Gallbladder: A Systematic Review of a Rare Biliary Anomaly. ANZ J Surg 2019;89:1392-7. doi: 10.1111/ans.15041
[6] Abongwa HK, De Simone B, Alberici L, Iaria M, Perrone G, Tarasconi A, et al. Implications of Left-sided Gallbladder in the Emergency Setting: Retrospective Review and Top Tips for Safe Laparoscopic Cholecystectomy. Surg Laparosc Endosc Percutan Tech 2017;27:220-7. doi: 10.1097/SLE.0000000000000417
[7] Lunevicius R, Haagsma JA. Supplementary Material to ‘Subtotal Cholecystectomy: Results of a Single-Centre, Registry-Based Retrospective Cohort Study of 180 Adults in 2011-2018. Version 1; 2020. doi: 10.17632/khv3b7b6wf.1 Available from: https://data. mendeley.com/datasets/khv3b7b6wf/1 [Last accessed on 2024 Jan 15].
[8] Nzenwa IC, Mesri M, Lunevicius R. Risks Associated with Subtotal Cholecystectomy and the Factors Influencing Them: A Systematic Review and Meta-Analysis of 85 Studies Published Between 1985 and 2020. Surgery 2021;170:1014-23. doi: 10.1016/j.surg.2021.03.036
[9] Lunevicius R. Review of the Literature on Partial Resections of the Gallbladder, 1898-2022: The Outline of the Conception of Subtotal Cholecystectomy and a Suggestion to Use the Terms “Subtotal Open-Tract Cholecystectomy” and “Subtotal Closed-Tract Cholecystectomy”. J Clin Med 2023;12:1230. doi: 10.3390/jcm12031230
[10] Okamoto K, Suzuki K, Takada T, Strasberg SM, Asbun HJ, Endo I, et al. Tokyo Guidelines 2018: Flowchart for the Management of Acute Cholecystitis. J Hepatobiliary Pancreat Sci 2018;25:55-72. doi: 10.1002/jhbp.516. Erratum in: J Hepatobiliary Pancreat Sci 2019;26:534.
[11] Idu M, Jakimowicz J, Iuppa A, Cuschieri A. Hepatobiliary Anatomy in Patients with Transposition of the Gallbladder: Implications for Safe Laparoscopic Cholecystectomy. Br J Surg 1996;83:1442-3.
[12] Lin HY, Lee RC. Is Right-Sided Ligamentum Teres Hepatis Always Accompanied by Left-Sided Gallbladder? Case Reports and Literature Review. Insights Imaging 2018;9:955-60.
[13] Gastrointestinal Quality of Life Index-10. GIQLI-10 © Ernst Eypasch. All Rights Reserved. Contact Information and Permission to Use. Lyon, France: Mapi Research Trust; 2018. Available from: https://eprovide.mapi-trust.org [Last accessed on 2023 Jan 31].
[14] Halle-Smith JM, Hodson J, Stevens LG, Dasari B, Marudanayagam R, Perera T, et al. A Comprehensive Evaluation of the Long-Term Economic Impact of Major Bile Duct Injury. HPB (Oxford) 2019;21:1312-21.
[15] Gartland RM, Bloom JP, Fong ZV, DeRoo C, Dwyer K, Quinn G, et al. What have we Learned from Malpractice Claims Involving the Surgical Management of Benign Biliary Disease? A 128 Million Dollar Question. Ann Surg 2019;269:785-91. doi: 10.1097/SLA.0000000000003155
[16] Farooq A, Bae J, Rice D, Moro A, Paredes AZ, Crisp AL, et al. Inside the Courtroom: An Analysis of Malpractice Litigation in Gallbladder Surgery. Surgery 2020;168:56-61.
[17] Hsu SL, Chen TY, Huang TL, Sun CK, Concejero AM, Tsang LL, et al. Left-sided Gallbladder: Its Clinical Significance and Imaging Presentations. World J Gastroenterol 2007;13:6404-9. doi: 10.3748/wjg.v13.i47.6404
[18] Couinaud C. Surgical Anatomy of the Liver Revisited. Paris: C. Couinaud; 1989.
[19] Burnand KG, Black J, Corbett SA, Thomas WE, editors. Browse’s Introduction to the Symptoms and Signs of Surgical Diseases. United States: CRC Press, Taylor and Francis Group; 2015.
[20] Zoulamoglou M, Flessas I, Zarokosta M, Piperos T, Papapanagiotou I, Birbas K, et al. Left-sided Gallbladder (Sinistroposition) Encountered during Laparoscopic Cholecystectomy: A Rare Case Report and Review of the Literature. Int J Surg Case Rep 2017;31:65-7. doi: 10.1016/j.ijscr.2017.01.011
[21] Pereira R, Perera M, Roberts M, Avramovic J. Surgical Approach to a Left-Sided Gallbladder. BMJ Case Rep 2019;12:e230681. doi: 10.1136/bcr-2019-230681
[22] Roli I, Colli F, Mullineris B, Esposito S, Piccoli M. Left Sided Gallbladder: A Case Report During Laparoscopic Cholecystectomy for Acute Cholecystitis. Int J Surg Case Rep 2020;77S: S34-6. doi: 10.1016/j.ijscr.2020.10.046.
[23] Abe T, Kajiyama K, Harimoto N, Gion T, Shirabe K, Nagaie T. Resection of Metastatic Liver Cancer in a Patient With a Left-Sided Gallbladder and Intrahepatic Portal Vein and Bile Duct Anomalies: A Case Report. Int J Surg Case Rep 2012;3:147-50. doi: 10.1016/j.ijscr.2012.01.003
[24] Ishii H, Noguchi A, Onishi M, Takao K, Maruyama T, Taiyoh H, et al. True Left-Sided Gallbladder with Variations of Bile Duct and Cholecystic Vein. World J Gastroenterol 2015;21:6754-8. doi: 10.3748/wjg.v21.i21.6754
[25] Hirohata R, Abe T, Amano H, Kobayashi T, Nakahara M, Ohdan H, et al. Laparoscopic Cholecystectomy for Acute Cholecystitis in a Patient with Left-Sided Gallbladder: A Case Report. Surg Case Rep 2019;5:54. doi: 10.1186/s40792-019-0614-9
[26] Armstrong CP. Hepatobiliary Anatomy in Patients with Transposition of the Gallbladder: Implications for Safe Laparoscopic Cholecystectomy. Br J Surg 1997;84:427. doi: 10.1002/bjs.1800840356
[27] Mesri M, Nzenwa IC, Lunevicius R. Evaluating the Patient and Setting-Specific Factors That Influenced the Quality of Informed Consent in a Retrospective Cohort of Subtotal Cholecystectomy Patients. J Laparoendosc Adv Surg Tech A 2021;31:77-84. doi: 10.1089/lap.2020.0376
[28] Griffiths EA, Hodson J, Vohra RS, Marriott P, CholeS Study Group, Katbeh T, et al. Utilisation of an Operative Difficulty Grading Scale for Laparoscopic Cholecystectomy. Surg Endosc 2019;33:110-21. doi: 10.1007/s00464-018-6281-2. Erratum in: Surg Endosc 2018 Aug 22; Erratum in: Surg Endosc 2023;37:2415.
[29] Nguyen TH, Nguyen TS, Van Nguyen PD, Dang TN, Talarico EF Jr. Sinistroposition: A Case Report of True Left-Sided Gallbladder in a Vietnamese patient. Int J Surg Case Rep 2018;51:82-5. doi: 10.1016/j.ijscr.2018.08.018.
[30] Sugiura T, Nagino M, Kamiya J, Nishio H, Ebata T, Yokoyama Y, et al. Infraportal Bile Duct of the Caudate Lobe: A Troublesome Anatomic Variation in RightSided Hepatectomy for Perihilar Cholangiocarcinoma. Ann Surg 2007;246:794-8. doi: 10.1097/SLA.0b013e3180f633de
[31] Kitami M, Takase K, Murakami G, Ko S, Tsuboi M, Saito H, et al. Types and Frequencies of Biliary Tract Variations Associated with a Major Portal Venous Anomaly: Analysis with Multi-Detector Row CT Cholangiography. Radiology 2006;238:156-66. doi: 10.1148/radiol.2381041783
[32] Ohkubo M, Nagino M, Kamiya J, Yuasa N, Oda K, Arai T, et al. Surgical Anatomy of the Bile Ducts at the Hepatic Hilum as Applied to Living Donor Liver Transplantation. Ann Surg 2004;239:82-6. doi: 10.1097/01.sla.0000102934.93029.89
[33] Ozden I, Kamiya J, Nagino M, Uesaka K, Sano T, Nimura Y. Clinicoanatomical Study on the Infraportal Bile Ducts of Segment 3. World J Surg 2002;26:1441-5. doi: 10.1007/s00268-002-6544-9
[34] Serban D, Badiu DC, Davitoiu D, Tanasescu C, Tudosie MS, Sabau AD, et al. Systematic Review of the Role of Indocyanine Green Near-Infrared Fluorescence in Safe Laparoscopic Cholecystectomy (Review). Exp Ther Med 2022;23:187. doi: 10.3892/etm.2021.11110
[35] NHS Digital. Classifications Browser OPCS-4.10. Available from: https://classbrowser.nhs.uk/#/book/OPCS4.10 [Last accessed on 2023 May 08].
[36] Lunevicius R, Haagsma JA. Subtotal Cholecystectomy: Results of a Single-Center, Registry-Based Retrospective Cohort Study of 180 Adults in 2011-2018. J Laparoendosc Adv Surg Tech A 2021;31:1019-33. doi: 10.1089/lap.2020.0713
[37] Van Dijk AH, Donkervoort SC, Lameris W, De Vries E, Eijsbouts QA, Vrouenraets BC, et al. Shortand Long-Term Outcomes after a Reconstituting and Fenestrating Subtotal Cholecystectomy. J Am Coll Surg 2017;225:371-9.
[38] Loh AY, Chean CS, Durkin D, Bhatt A, Athwal TS. Short and Long Term Outcomes of Laparoscopic Fenestrating or Reconstituting Subtotal Cholecystectomy Versus Laparoscopic Total Cholecystectomy in the Management of Acute Cholecystitis. HPB (Oxford) 2022;24:691-9. doi: 10.1016/j.hpb.2021.09.018
[39] Lunevicius R, Nzenwa IC. Multiple Logistic Regression Model to Predict Bile Leak Associated with Subtotal Cholecystectomy. Surg Endosc 2023;37:5405-13.
[40] Chowbey P, Sharma A, Goswami A, Afaque Y, Najma K, Baijal M, et al. Residual Gallbladder Stones After Cholecystectomy: A Literature Review. J Minim Access Surg 2015;11:223-30. doi: 10.4103/0972-9941.158156