Gangrenous Gallbladder Research Articles

Multiple ileal perforations and concomitant cholecystitis with gall bladder gangrene as complication of typhoid fever

Surgical complications of typhoid fever usually involve the small gut, but infrequently typhoid fever also involves the gallbladder. Complications range from acalculous cholecystitis, gangrene to perforation. Here, we present a case of enteric fever with concomitant complication of multiple ileal perforations at its terminal part with acalculous cholecystistis with gangrenous gall bladder. The primary closure of the perforations and cholecystectomy was performed. Post-operatively patient developed low-output faecal fistula that was managed conservatively.

Gallbladder torsion: a diagnostic challenge.

80-year-old female presented with clinical findings suggestive of acute cholecystitis. Intraoperatively we discovered a dusky gallbladder with gangrenous patches and gallbladder torsion with 270 degrees clockwise rotation along the longitudinal axis. Gallbladder torsion is a rare cause of acute cholecystitis with less than 500 cases published in the literature. Gallbladder torsion should be included in the list of differential diagnoses in patients suspected of having acute cholecystitis especially when there are inconsistencies between clinical features and imaging. It is worth noting that 3-dimensional reconstructed CT may be useful in preoperative diagnosis of gallbladder torsion.

Acute Torsion of the Gallbladder

An 89 year old man presented to the emergency department with a two days history of acute onset abdominal pain in the upper right quadrant, with fever, vomiting and malaise. His medical history included peptic ulcer disease and tobacco abuse. There was no significant relevant past surgical history. He was dehydrated at presentation with the following vital signs: HR86 b/min, BP-100/50 mmHg, T-38.5°C. Focused abdominal examination demonstrated tenderness to palpation in the right upper quadrant, and a positive Murphy’s sign. Laboratory blood tests revealed a leukocytosis of 22.7×103/L, C-reactive protein of 48 mg/L and normal kidney and liver function tests. Abdominal ultrasonography (Figure 1) and computed tomography (CT) scan (Figure 2) showed a clearly enlarged gallbladder with a thickened wall of 7 mm, with fluid sub-hepatically. They demonstrated no gallstone. Free air within the gallbladder wall was not seen. He was admitted to our hospital with the diagnosis of acute cholecystitis. After resuscitation emergency laparotomy through a midline incision was performed. On entering the abdominal cavity, a gangrenous distended gallbladder with omentum adhesed to it circumferentially was immediately noted (Figure 3). It was rotated more than 360 degrees anticlockwise around its mesentery. The gallbladder torsion was reduced and a cholecystectomy was then performed in the standard fashion, with placement of a drain in the gallbladder fossa. No gallbladder stones were found in the specimen. Histology revealed transmural necrosis consistent with volvulus. His post-operative course was unremarkable and he was discharged on post-operative day 3.

Contrast-enhanced ultrasonographic image of gangrenous gallbladder.

A 6-year-old Japanese boy was admitted to our hospital because of right hypochondrial discomfort, which had started 6 h earlier. His medical history was unremarkable. A physical examination revealed rebound tenderness in the right upper quadrant associated with a low-grade fever (37.4 C). Laboratory tests at presentation showed an increased white cell count of 11,700/lL (normal range 3700–8000) and C-reactive protein 2.56 mg/dL (normal range 0.00–0.29). Liver and renal function tests were normal. Conventional gray-scale transabdominal ultrasonography (US) using the ProSound a10 (Hitachi-Aloca Medical Co., Tokyo, Japan) with a 3.5-MHz transducer demonstrated an enlarged gallbladder with a grossly thickened wall, and a small amount of pericholecystic fluid (Fig. 1). The sonographic Murphy’s sign was positive. There was no evidence of gallbladder stones. Based on the conventional US, our initial diagnosis was acute cholecystitis. However, the gallbladder wall was unusually thickened for typical acute cholecystitis, so we evaluated the blood flow of the gallbladder wall. Doppler imaging confirmed the flow in the cholecystic artery at the neck of the gallbladder, but no blood flow within the gallbladder wall was observed, which was inconsistent with acute cholecystitis [2]. Therefore, CEUS using Sonazoid (Daiichi-Sankyo, Tokyo, Japan) was performed to further assess the gallbladder vascularity, since CEUS is more sensitive in detecting the blood flow than nonenhanced color Doppler US [3]. Sonazoid diluted in 10 mL of saline solution was administered intravenously at 0.015 mL/kg over 3–5 s. Five seconds after administering the Sonazoid , the gallbladder wall was enhanced from the serosal side, and then the mucosal line was enhanced linearly a second later (Figs. 2, 3). Based on a preoperative diagnosis of acute cholecystitis due to incomplete gallbladder torsion, the boy underwent an emergency laparotomy. At surgery, the gallbladder was markedly swollen and the cystic duct had twisted 180 in a counter-clockwise manner around the mesentery (Fig. 4). Y. Yashima (&) T. Tsujino R. Nakata Department of Gastroenterology, Japanese Red Cross Medical Center, 4-1-22 Hiroo, Shibuya-ku, Tokyo 150-8935, Japan e-mail: y-yashima@umin.ac.jp

Gangrenous cholecystitis in an asymptomatic patient found during an elective laparoscopic cholecystectomy: a case report

IntroductionGangrenous cholecystitis is a severe complication of acute cholecystitis. We present an unusual case of gangrenous cholecystitis which was totally asymptomatic, with normal pre-operative parameters, and was discovered incidentally during a laparoscopic cholecystectomy. We have not found any similar cases in the published literature.Case presentationA 79-year-old British Caucasian man presented initially with acute cholecystitis which responded to conservative management. After six weeks he was asymptomatic and had normal blood parameters. An elective laparoscopic cholecystectomy was performed and our patient was found to have a totally gangrenous gall bladder.ConclusionIt is important to keep a high index of suspicion for the diagnosis of gangrenous cholecystitis in order to avoid potentially serious complications.

Portal Venous Gas Secondary to Gangrenous Gallbladder and Mirizzi Syndrome Diagnosed by Gray-Scale Sonography but Not on 64-Slice MDCT: A Case Report and Literature Review

Portal venous gas is a rare entity that is associated with many fatal and nonfatal conditions. Its exact etiology remains unclear. Computed tomography (CT) has been described as a sensitive and primary imaging tool for detecting this condition, but there are only a few case reports in the literature where portal venous gas was not detected on CT scan but was found by sonography. This case reports portal venous gas developing secondary to gangrenous gallbladder with Mirizzi syndrome which was diagnosed by sonography but remained undetected on 64-slice MDCT.

Difficult Laparoscopic Cholecystectomy-When and Where is the Need to Convert?

Laparoscopic cholecystectomy has now become the treatment of choice for the gall bladder stone. With increasing experience, surgeon has started to take more difficult cases which were considered relative contra indications for laparoscopic removal of gall bladder few years back. We conducted this study at our hospital and included all laparoscopic cholecystectomy done from May'08 to January'10. Total time taken in surgery, conversion rate and complication rate were analysed. Factors making laparoscopic cholecystectomy difficult were also analysed. We defined difficult laparoscopic cholecystectomy when we found -dense fibrotic adhesions in and around Callot's triangle, gangrenous gall bladder, empyma, large stone impacted at gall bladder neck, contracted gall bladder, Mirrizi's syndrome, h/o biliary pancreatitis, CBD stones, acute cholecystitis of Out of 206 cases done during above period, 56 cases were considered difficult. Only two cases were converted to open. With growing experience and technical advancement surgery can be completed in most of the difficult cases. This is important because recently it is shown in literature that laparoscopic cholecystectomy is associated with less morbidity than open method irrespective of duration of the surgery.

Unusual hernia in a colostomy closure site

This is a case report of an interstitial hernia following previous transverse loop colostomy closure. There are no reported cases in the literature of gangrenous gall-bladder as the content of an interstitial hernia. This condition can present as a diagnostic challenge. We present a case with a previous reversal of a colostomy in the right upper quadrant presenting with a short history of a right iliac fossa mass and tenderness. Clinically, the patient was septic without any peritonitis. Subsequent computed tomography scan suggested the hernial sac contained gall-bladder and loops of bowel. At surgery, a gangrenous gall-bladder was found within an interstitial incisional hernia (between the external and internal oblique muscle). Retrograde cholecystectomy was performed and bowel and hernia were reduced. The hernia was repaired in layers and patient had an uneventful recovery.

Acute transient hepatocellular injury in cholelithiasis and cholecystitis without evidence of choledocholithiasis

To investigate acute transient hepatocellular injury in patients with cholelithiasis and cholecystitis but no evidence of choledocholithiasis. The medical records of patients with cholelithiasis who underwent cholecystectomy between July 2003 and June 2007 were retrospectively reviewed. Imaging studies to detect common bile duct (CBD) stones were performed in 186 patients, who constituted the study population. Biochemical liver tests before and after surgery, and with the presence or absence of CBD stones were analyzed. In 96 patients with cholelithiasis and cholecystitis without evidence of CBD stones, 49 (51.0%) had an alanine aminotransferase level elevated to 2-3 times the upper limit of normal, and 40 (41.2%) had an elevated aspartate aminotransferase level. Similar manifestations of hepatocellular injury were, as would be expected, even more obvious in the 90 patients with CBD stones. These markers of hepatocellular injury resolved almost completely within 2 wk to 1 mo after cholecystectomy. Compared to 59 patients with histologically less severe cholecystitis in the group undergoing urgent surgery (total 74 patients), the 15 patients with a gangrenous gallbladder had a higher mean level of total bilirubin (1.14 +/- 1.27 mg/dL vs 2.66 +/- 1.97 mg/dL, P < 0.001) and white cell count (9480 +/- 4681/microL vs 12840 +/- 5273/microL, P = 0.018). Acute hepatocellular injury in cholelithiasis and cholecystitis without choledocholithiasis is mild and transient. Hyperbilirubinemia and leukocytosis may predict severe inflammatory changes in the gallbladder.

Recurring abdominal wall wounds and cutaneous sinus tract formations secondary to spilled gallstones

Introduction: Perforation of an inflamed, gangrenous gallbladder during laparoscopic cholecystectomy inevitably leads to intraoperative spillage of bilious contents and possibly gallstones. In rare cases, spilled gallstones that escape detection during laparoscopic surgical field washout can predispose to multiple types of complications, which are documented in the surgical literature, in the months to years following surgery.Results and Discussion: Spilled gallstones can embed within the abdominal wall musculature in the months following laparoscopic cholecystectomy and serve as a nidus for inflammation and infection. This case demonstrates an instance of simultaneous development of chronically draining wounds and complex cutaneous sinus tracts in both the right flank and periumbilical area secondary to spilled gallstones. These complications began one year after laparoscopic cholecystectomy.Conclusion: Surgical removal of spilled gallstones is necessary to avoid the rare instances where they produce complications of infection, inflammation, and cutaneous sinus tract formations. A 70-year-old female patient presented to our service for evaluation of two separate chronically draining abdominal wall wounds refractory to treatment that developed one year after undergoing a laparoscopic cholecystectomy. After several surgical interventions provided only temporary resolution with eventual recurrence of drainage from the wounds, retained gallstones were discovered as the underlying problem. Overall occurrence of gallstone spillage is documented as occurring in 5%-40% of laparoscopic cholecystectomy cases but sequelae of spilled gallstones are quite rare, appearing in only 0.08%-0.3% of patients.1

Laparoscopic Treatment of Gallbladder Volvulus: A Pediatric Case Report and Literature Review

Volvulus of the gallbladder has been reported mostly in elderly women and is rarely reported in children. In this paper, we report a recent case of successful detorsion and removal of the gallbladder via minimal access surgery, which was diagnosed as gallbladder volvulus preoperatively by means of magnetic resonance imaging (MRI). An 11-year-old boy presented with an acute abdomen, and acute cholecystitis was suspected, based on the findings of ultrasound and computed tomography. However, a diagnosis of gallbladder volvulus was established through MRI, and emergency laparoscopic surgery was subsequently performed. Laparoscopy revealed a hemorrhagic, gangrenous gallbladder that floated anteriorly. The gallbladder was rotated twice around its pedicle in a counterclockwise direction. It was untwisted through laparoscopy, and a cholecystectomy was performed without difficulty. To achieve an early, prompt preoperative diagnosis, MRI could be an effective alternative to conventional imaging modalities. The advent of laparoscopic detorsion and cholecystectomy as a treatment for gallbladder volvulus allows less invasive treatment, a shorter hospital stay, and better cosmesis, which are highly desirable in children.

The use of laparoscopic subtotal cholecystectomy for complicated cholelithiasis

The risk of damage to the bile duct and structures in the hilum of the liver is significant when Calot's triangle cannot be safely dissected during laparoscopic cholecystectomy, and conversion to an open procedure often is performed. This is more common during emergency surgery, but may not render the procedure any easier. Traditionally, open subtotal cholecystectomy was performed, but with the advent of laparoscopic surgery, this has fallen from favor. The authors report their experience using laparoscopic subtotal cholecystectomy to avoid bile duct injury and conversion in difficult cases. Laparoscopic subtotal cholecystectomy, performed when the cystic duct cannot be identified safely, consists of resecting the anterior wall of the gallbladder, removing all stones, and placing a large drain into Hartmann's pouch. The notes for all patients who underwent a laparoscopic subtotal cholecystectomy between 1 September 2001 and 31 December 2004 were retrospectively analyzed. Subtotal cholecystectomy was performed in 26 cases including 13 emergency and 13 elective procedures. The median age of the patients (15 women and 11 men) was 68 years (range, 36-86 years). The indications were severe fibrosis in 16 cases, inflammatory mass or empyema in 8 cases, and gangrenous gallbladder or perforation in 2 cases. The median postoperative inpatient stay was 5 days (range, 2-26 days). Five patients underwent postoperative endoscopic retrograde cholangiopancreatography: four for persistent biliary leak and one for a retained common bile duct stone. One patient required laparotomy for subphrenic abscess, and one patient (American Society of Anesthesiology [ASA] grade 4, presenting with biliary peritonitis) died 2 days postoperatively. One patient required a subsequent completion laparoscopic cholecystectomy for a retained gallstone. One patient had a chest infection, and two patients experienced port-site hernias. Laparoscopic subtotal cholecystectomy is a viable procedure during cholecystectomy in which Calot's triangle cannot be dissected. It averts the need for a laparotomy.

Choledochal Semi Volvulus with Normal LFTs: A Complication of Paraesophageal Hernia, with Literature Review

86 year old lady presented with sudden onset of sub-sternal and epigastric pain, with radiation to the neck and the back, associated with nausea, palpitation, diaphoresis, and vomiting dark material. PMH: Long standing hiatal hernia with bloating, belching, and chest discomfort. BP 220/110. All labs normal except troponin slightly elevated 0.06. Initial diagnosis: Acute Coronary Syndrome. Urgent Cardiac catherization was normal. CT of the abdomen revealed a large paraesophageal hernia with all of the stomach located intra-throacically, with possible incarceration, along with a hugely distended gallbladder, with dilation of CBD to 13 mm with no gallstones. Patient was taken to OR for reduction and fixation of hernia. An abdominal approach was taken, upon opening of the abdomen a large hemorrhagic, gangrenous gallbladder was seen along with hiatus hernia with pulled cholodocal ductal system along with the tenting of duodenum. Intraoperative cholangiogram showed no filling defect or gall stones. Patient underwent cholecystectomy along with reduction and fixation of hiatus hernia. Literature Review: 4 similar cases have been reported. Miller and Thompson (1977): Intermittent dislocation of Liver; A syndrome associated with volvulus of stomach, transverse colon and obstructive jaundice. Llaneza PP et al. (1986): Extrahepatic obstruction of CBD at the diaphragmatic hiatus in association with intrathoracic volvulus. Lamouliatte et al. (1992): Biliary obstruction complicating diaphragmatic hiatus hernia with jaundice due to choledochal dislodgement and torsion. Caldiero et al. (2001): Choledochal semi volvulus with jaundice due to hiatal hernia. All the 4 cases presented with cholestatic syndrome secondary to either obstruction or stretching of CBD in the diaphragmatic hiatus and hiatus hernia was diagnosed retrospectively. By contrast, our patient presented with chest/ epigastric pain with normal LFTs and was subsequently found to have gangrenous acalculous cholecystitis in association with incarcerated hiatus hernia. This observation emphasizes the possibility of direct relationship of gangrenous cholecystitis and hiatus hernia even with normal LFT, could be due to intermittent stretching or tension of CBD. If time permits HIDA scan is recommended to confirm the diagnosis. But, if the clinical suspicion is high, an abdominal approach is recommended to repair the volvulus and at the same time explore the gallbladder to reduce the added mortality of these coexisting clinical entities.

Unusual abdominal manifestations of catastrophic antiphospholipid syndrome

A 40-year-old woman with newly diagnosed Graves’ disease was admitted for carbimazole-induced agranulocytosis. Upon recovery of leucopenia, she developed acute onset of thrombocytopenia, renal failure and microangiopathic haemolytic anaemia. Contrast-enhanced computed tomography of the abdomen (left panel) performed for deranged liver enzymes showed a complete splenic infarct (yellow arrow) and multiple hepatic nodules (red arrows), which were initially thought to be abscesses. Ultrasound-guided fine needle aspiration and core liver biopsy of these nodules identified solid hepatic lesions inconsistent with abscesses. Histology yielded necrotic tissue with no morphological or microbiological evidence of fungal or bacterial infection. Lupus anticoagulant detection by both activated partial thromboplastin time and dilute Russell’s viper venom test with respective confirmatory tests was positive on four separate occasions within 1 month. Immunoassays for anticardiolipin IgG and IgM were, however, negative. A probable diagnosis of catastrophic antiphospholipid syndrome (CAPS) was made. Treatment with unfractionated heparin, intravenous immunoglobulin and plasmaphaeresis was initiated. Severe haematochezia and intra-abdominal sepsis unresponsive to conservative measures (including broad spectrum antibacterial and empiric antifungal therapy) ensued. This necessitated an exploratory laparotomy, which revealed that the spleen had liquefied with coagulative necrosis and had eroded into the splenic flexure of the colon. Additional findings included a gangrenous gall bladder and necrotic liver nodules. Splenectomy, cholecystectomy and segmental colonic resection were performed. The patient developed a right pleural effusion (right panel), which drained fluid and necrotic tissue. Recurrent uncontrolled bleeding from the gastrointestinal tract necessitated a second laparotomy, which revealed necrotic liver nodules eroding into and possibly perforating the gastric fundus, and a thinned-out diaphragm allowing the translocation of abdominal contents into the pleural cavity. Histologic sections of the resected spleen and liver showed complete infarction with the presence of thrombi occluding the larger blood vessels. Small vessel occlusion, however, was not apparent because of the extensive infarction. Cultures of resected tissues and pleural fluid yielded mixed bacterial and fungal infection, which probably occurred secondary to CAPS. The patient unfortunately succumbed to her illness. This case illustrates that CAPS can lead to acute multi-organ failure and can be associated with infections, both of which can result in challenging surgical management issues. Early recognition is essential for effective life-saving treatment to be instituted.

Volvulus of the gall bladder diagnosed by ultrasonography, computed tomography, coronal magnetic resonance imaging and magnetic resonance cholangio-pancreatography

A 54-year-old woman was admitted to our hospital with the complaint of right upper quadrant pain. Upon physical examination the vital signs of the patient were within normal ranges. Ultrasonography and computed tomography (CT) examination of the abdomen was obtained, which demonstrated a large dilatated cystic structure, measuring approximately 68.6 mm multiply 48.6 mm, with marked distension and inflammation. Additionally, the enhanced CT was characterized by the non-enhanced wall of the gallbladder. As the third examination in this study, magnetic resonance imaging (MRI), namely coronal MRI and magnetic resonance cholangio-pancreatogra (MRCP), were performed. The MRCP demonstrated a dilatation of the gallbladder but detected no neck of the gallbladder. Simple cholecystectomy was performed. Macroscopic findings included a distended and gangrenous gallbladder, and closer examination revealed a counterclockwise torsion of 360 degrees on the gallbladder mesentery. Coronal MRI and MRCP showing characteristic radiography may be useful in making a definitive diagnosis.

Cholecystectomy in the elderly: A prospective study

The mortality and morbidity of 151 elderly patients (greater than 64 years of age) undergoing biliary surgery for benign disease were prospectively studied. The overall mortality was 3.3 per cent. This comprised a 0.77 per cent mortality in the elective group and a 19 per cent mortality in the emergency group. In spite of 77 per cent of the emergency group having a gangrenous gallbladder, a complication difficult to predict preoperatively, the majority of deaths were from cardiovascular disease. The overall incidence of common bile duct exploration was 36 per cent, which was similar in the elective and emergency groups. A comparison between the old (65-74 years) and the aged (over 74 years of age) revealed twice the number of emergency cases in the aged. Considering elective biliary surgery, there was no difference between the mortality, morbidity, or common bile duct exploration rate comparing the old with the aged. This suggests that elective biliary surgery is safe even in the aged.

Rim Sign in Tc-99m Sulfur Colloid Hepatic Scintigraphy

A case of pericholecystic hyperperfusion on Tc-99m sulfur colloid (SC) flow images with a pericholecystic rim of increased activity (PCHA) on delayed planar and single-photon emission computed tomography images of the liver was seen in a patient with a history of multiple renal transplants admitted with cramping right lower quadrant abdominal pain. Laparotomy performed 5 days after the scan revealed an acutely perforated gangrenous gallbladder and occluded cystic duct. The secondary findings of gallbladder hyperperfusion and PCHA or "rim sign" have been frequently reported with Tc-99m IDA hepatobiliary imaging. These secondary findings in conjunction with a nonvisualized gallbladder on an IDA scan suggest a complicated or advanced stage of acute cholecystitis and usually require urgent surgical intervention. The rim sign on Tc-99m SC scintigraphy also likely indicates the same grave diagnosis.

Can gangrenous cholecystitis be prevented?: a plea against a "wait and see" attitude.

A delay in recognizing and treating an inflamed gallbladder may increase the risk of a necrotic evolution and represent a critical factor affecting the progression of the inflammatory process. Aim of the study is to assess the therapeutic attitude in patients with histologically proved gangrenous cholecystitis, to find out whether it could play a role in the progression of the inflammatory condition. Twenty-seven patients with gangrenous cholecystitis at histology were compared with a matched-control group with phlegmonous cholecystitis. Age, gender, ASA score, and concomitant diseases did not differ significantly in both groups. WBC was significantly higher (P = 0.026) in patients with gangrene. Ultrasounds were unhelpful in identifying the severity of the disease. Patients with gangrenous gallbladder showed a significantly increased (P = 0.0006) admission delay compared with controls (104.3+/-15.3 hours vs. 59.7+/-7.7 hours). Surgeon's delay, morbidity and mortality were not different in both groups. Patient's delay before hospitalization may represent a crucial factor in the progression toward a more severe disease in acute cholecystitis. The time between symptoms onset and hospital admission (and consequently surgery) was significantly longer in patients with gangrenous cholecystitis, further emphasizing the need for an early (if not urgent) surgical treatment in acute cholecystitis, even with mild symptoms.

Laparoscopic cholecystectomy for acute cholecystitis and the consequences of gallbladder perforation, bile spillage, and "loss" of stones.

To study the factors associated with accidental perforation of the gallbladder and spillage of bile and stones and to assess the consequences of these mishaps. Prospective study with retrospective bacteriological evaluation. Teaching hospital, Israel. 189 Patients who were treated for clinical acute cholecystitis between January 1994 and August 1996. Emergency laparoscopic cholecystectomy. Incidence of accidental perforation of gallbladder and spillage of bile and stones and of conversion and complications in relation to preoperative and operative findings. Bile was spilt in 65 (34%) and gall-stones were "lost" in 27 (14%), 44 (23%) required conversion to an open approach and 36 (19%) developed complications. Preoperative duration of symptoms >96 hours and a palpable gallbladder were associated with accidental perforation of the gallbladder and spillage of bile. A palpable gallbladder, gangrenous cholecystitis, and WBC > 15 x 10(9)/L were associated with stones "lost" in the peritoneum. A history of biliary disease was inversely related to "lost" stones. Conversion of laparoscopic to open cholecystectomy was associated with male sex, age >60 years, a non-palpable gallbladder, WBC > 15 x 10(9)/L, and a gangrenous gallbladder. Complications of surgery were more common among men and associated with fever of >38 degrees C. Neither the conversion nor the complications were associated with perforation of the gallbladder or "lost" stones. Perforation of the gallbladder and intraperitoneal spillage of bile or stones during laparoscopic cholecystectomy for acute cholecystitis are not associated with undesirable events, are not indications for conversion, and are not associated with further complications. When patients are given appropriate antibiotics perioperatively and the spilt bile is properly aspirated and the peritoneum irrigated, the operative and postoperative courses are similar to those of patients with unperforated gallbladder.

Complete gallbladder and cystic pedicle torsion Laparoscopic diagnosis and treatment

Complete gallbladder torsion is an unusual emergency that requires immediate surgical treatment. Since it was first reported in 1898, <400 cases have been described in the literature, and only three of them were diagnosed and treated by laparoscopic cholecystectomy. Our objective here is to describe an approach that allows a definitive diagnosis and treatment. First we present the case of a febrile 81-year-old woman with acute right upper quadrant pain. Ultrasound showed an alithiasic distended gallbladder with a multilayered wall and a transverse orientation. When exploratory laparoscopy was performed, a gangrenous gallbladder secondary to a 360 degrees clockwise cystic pedicle torsion was found. Laparoscopic decompression, detorsion, and cholecystectomy with an intraoperative cholangiogram were completed. The patient was discharged 72 h later. Next, several preoperative diagnostic methods are reviewed. We conclude that the laparoscopic treatment of this entity is feasible and obviates the performance of unnecessary and nonspecific tests. It offers a favorable and rapid postoperative recovery, in addition to the other well-known advantages of the minimally invasive surgical approach.