Objective: To identify and document the clinico-anatomical variations of hepatobiliary vascular structures and gallbladder observed during laparoscopic cholecystectomy.Methodology: This descriptive cross-sectional study was conducted at Fauji Foundation Hospital, Rawalpindi, Pakistan, from January 2024 to June 2025. A total of 350 patients who underwent elective laparoscopic cholecystectomy for symptomatic cholelithiasis were included. Intraoperative findings were carefully recorded to identify variations in the cystic artery, cystic duct, hepatic arteries, and gallbladder morphology.Results: Out of the 350 patients who underwent laparoscopic cholecystectomy, 221 (63.1%) were female and 129 (36.9%) were male, with a mean age of 42.6±11.3 years. Clinico-anatomical variations were observed in 112 patients (32%). Cystic artery variations were noted in 84 patients (24%). The most common variation was a short cystic artery arising from the right hepatic artery (n=47; 13.4%), followed by a double cystic artery (n=21; 6%). In 16 cases (4.6%), the cystic artery originated from the aberrant right hepatic artery. Cystic duct anomalies were observed in 28 patients (8%), including low insertion (n=12; 3.4%), medial insertion (n=9; 2.6%), and short cystic duct (n=7; 2%). Anomalies in gallbladder position or shape were observed in 18 patients (5.1%). These included intrahepatic gallbladder (n=7), Phrygian cap deformity (n=6), and left-sided gallbladder (n=5).Conclusion: Clinico-anatomical variations in hepatobiliary vasculature and gallbladder are frequently encountered during laparoscopic cholecystectomy. A thorough understanding of these variants is crucial for minimizing surgical risks and improving patient outcomes.Keywords: Anatomic Variation, Bile Ducts, Cholecystectomy, Extrahepatic, Gallbladder, Hepatic Artery, Laparoscopic, Vascular System Abnormalities.

IntroductionThe coexistence of gallbladder (LSG) and adenomyomatosis (ADM) is extremely uncommon presenting a novel clinical dilemma that has not been previously documented. LSG refers to a anomaly where the gallbladder is situated to the left of the round ligament deviating from its usual position. This anomaly is rare, with reported occurrences ranging between 0.04% and 1.1%. Identifying LSG before surgery poses challenges. It is often discovered incidentally during procedures necessitating surgical expertise to safely manage anatomical variations.Case presentationWe report an old man with a history of hepatitis C, carcinoma and liver cirrhosis complained of sudden epigastric pain. A CT scan revealed the presence of an LSG, which’s a congenital anomaly. During the cholecystectomy procedure surgeons encountered variations and observed the existence of ADM complicating the operation. The patient recovered smoothly post surgery.DiscussionThis case shows how complicated it can be to diagnose and treat the combination of LSG and ADM. Identifying these conditions before surgery is tough so surgeons often have to adjust their approach during the operation. Although laparoscopic cholecystectomy for LSG is usually safe it requires care to avoid problems like bile duct injuries. For patients at risk a conservative treatment approach might be better. In cases where surgery is necessary surgeons need to adapt their techniques to address the unique anatomical issues.ConclusionThe combination of LSG and ADM in a setting poses an intricate challenge. Surgeons need to be ready to recognize and address these abnormalities effectively for the well being of the patient and favorable results. This particular case highlights the importance of staying alert and flexible during surgery when dealing with gallbladder variations.

Left-sided gallbladder (LSG) is a rare congenital anomaly where the gallbladder is located to the left of the round ligament. It can occur alone or as part of situs inversus syndrome. Gilbert Syndrome (GS) is a benign hereditary condition characterized by intermittent unconjugated hyperbilirubinemia. We describe the case of a young male patient presenting with jaundice and symptomatic cholelithiasis found to have a left-sided gallbladder, with a known diagnosis of Gilbert Syndrome. This clinical finding highlights the importance of recognizing anatomical variants to avoid intraoperative complications and considering underlying liver status that might affect clinical interpretation.

Coexistence of adenomyomatosis in a left-sided gallbladder: a case report

Congenital hepatic anomalies may be associated with important intestinal abnormalities, vascular anomalies, or may be asymptomatic and discovered incidentally. Uncommon and rare anatomic liver and biliary disorders include left-sided gallbladder, wandering liver, malrotation of the liver, and hepato-diaphragmatic interposition of the bowel (Chilaiditi syndrome). This report describes an infant with incidentally discovered malpositioning of the gallbladder to the superior surface of the left hepatic lobe, coupled with Chilaiditi syndrome, a configuration that has not been described in the literature. Management considerations are discussed.

Left sided gallbladder (LSG) is a very rare clinical entity and most are diagnosed at operation. The patients usually present with features of biliary colic or pain in the right upper abdomen similar to normally positioned gallbladder. Ultrasonography is not a good diagnostic modality for diagnosing LSG and CT scan is better for the pre-operative diagnosis of the condition. Laparoscopic cholecystectomy can be done in patients with LSG and antegrade or fundus first technique is usually advocated.

Abstract Background Left-sided gallbladder (LSG) is a rare congenital anomaly in the gallbladder, which is defined as a gallbladder located on the left side of the falciform ligament and round ligament without situs inversus. (1) The reported prevalence of sinistroposition ranges from 0.2% to 1.1%. (2) There are three recognized variants of LSG: LSG associated with situs viscerum inversus, true LSG, and gallbladder located to the left of abnormally located right-sided round ligament/ ligamentum teres. Method We present a case of a gentleman who was diagnosed as having gall bladder sinistroposition intraoperatively, after all the laparoscopic ports had been placed as per a routine laparoscopic cholecystectomy. Although the gentleman had undergone preoperative MRCP, it was not reported by the radiologists as such. The surgery was carried out using the usual ports used for standard four-port laparoscopic cholecystectomy and demonstrates the difficulty faced by the surgeon with these ports. Results Critical view of safety was demonstrated. Gall bladder was removed in piece meal. Surgery lasted for more than 90 minutes. There were no post-operative complications. Suggested modifications include Right working port from the Palmers point(3) or using a robotic approach with the same standard configuration(4). Our reflection revealed – interchanging of 5 mm and 12 mm working ports could have been helpful for better access. Conclusion The presence of a left sided gall bladder is often associated with various biliary, portal venous and other anomalies that might lead to intra-operative injuries. (5) The diagnosis is usually incidental and is done intraoperatively. Hence surgeons must be aware of these possibilities.

Heterotaxy syndrome is a disorder of embryonic development resulting in anomalous thoracoabdominal organ determination of the left–right axis. It presents with cardiac and extracardiac abnormalities associated with significant morbidity and mortality. We managed a 3-year-and-5-month-old boy with heterotaxy, who presented with bilious emesis, abdominal pain, distension, and obstipation. After resuscitation and nasogastric tube placement, an upright abdominal x-ray revealed a distended, right-sided stomach with an air–fluid level. Exploratory laparotomy confirmed this finding and revealed a midline liver, left-sided gallbladder, shortened large bowel, and internal herniation. Initial surgery reduced the small bowel and pexyed the large bowel to the right. The patient presented with obstructive symptoms 14 days after discharge, requiring a duodenojejunostomy to bypass an annular pancreas. Heterotaxy is a rare condition with variable anatomical presentations that may cause obstructive symptoms, often requiring surgical intervention. These cases can be complex, especially due to the potential for multiple coexisting sources of obstruction.

Abstract Laparoscopic cholecystectomy is a minimally invasive surgical procedure used for the removal of a diseased gallbladder. Since the early 1990s, this technique has largely replaced the open technique for cholecystectomies. We present a unique incident where a left-sided gallbladder was incidentally discovered during a laparoscopic cholecystectomy, posing a technical challenge for the surgeon. Our patient was a 34-year-old female who visited our hospital with complaints of right upper abdominal pain and postprandial nausea lasting for three months. Ultrasound examination revealed two gallstones measuring 16mm and 13mm in the neck of the gallbladder. During the routine laparoscopic cholecystectomy, the surgeon encountered a left-sided gallbladder. To ensure a safe and effective dissection, an additional port was required during the surgical procedure. The prevalence of this rare congenital anomaly, known as a left-sided gallbladder, ranges from 0.1% to 0.7%. It is characterized by the gallbladder being located on the left side of the ligamentum teres and falciform ligament, with the cystic artery passing in front of the common bile duct from right to left. This anatomical variation is often associated with abnormalities in the biliary tree and the porto-venous system. Failing to recognize these variations can lead to serious complications, particularly in hepatobiliary surgery. Discovering a left-sided gallbladder during surgery is an infrequent finding that can increase the complexity and morbidity rate of the procedure.

Background: Left sided gall bladder is a rare anomaly encountered by surgeons. Choledochal cyst with pancreas divisum is also rare anomaly as reported in various studies. Here we are reporting a case of left sided gall bladder associated with choledochal cyst and pancreas divisum. Case Report: We had a 48-year male patient with symptoms of recurrent upper abdominal pain. On magnetic resonance cholangiopancreatography, type 4a choledochal cyst with cystolithiasis with pancreas divisum was documented. Minor pancreatic duct stenting was done for recurrent acute pancreatitis. After stenting patient developed severe necrotizing pancreatitis and cholangitis, which was managed conservatively with multiple percutaneous drainage and segment 3 percutaneous transhepatic biliary drainage. Later he underwent cholecystectomy with choledochal cyst excision with Roux-en-Y hepaticojejunostomy. In post-operative period, drain was serous and removed on day 5 and discharged on post-operative day 7. Conclusion: Till date no such case of left sided gall bladder with choledochal cyst and pancreas divisum has been reported.

A left-sided gallbladder (LSGB), also known as sinistropostition, is a rare anatomical variant with a reported incidence of 0.2-1.1%. It is defined as a gallbladder located on the left side of the falciform ligament, embedded in the third hepatic lobe, without situs inversus viscerum. A 37-year-old Latino man with a history of bilateral inguinal repair underwent a scheduled laparoscopic cholecystectomy due to multiple gallbladder polyps. Preoperative ultrasound reported a gallbladder of 60x20 mm, wall thickness of 1 mm, with polyps of up to 10 mm. Standard laparoscopic cholecystectomy trocar placement was used. Upon revision of the right hepatic lobe, there was an absence of the GB in the visceral side of segments IV, V, or VI. It was identified to the left of the falciform ligament with adhesions to the anterior and superior portions of the pylorus and lesser curvature. The subxiphoid trocar was adjusted to the left of the falciform ligament, and Calot’s triangle dissection was performed to obtain a critical view of safety. No other anatomical variants were identified. The procedure was performed safely with a satisfactory view of critical cholecystectomy steps and anatomy identification. After the procedure, the surgeon complained of right-hand pain and numbness due to a medial position of the subxiphoid trocar for dissection. The surgical approach of a LSGB in laparoscopic surgery should be individualized for each patient. A minimally invasive approach may be realized successfully when critical thinking by the surgeon is applied and always prioritizing the safety of the patient.

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.

Left-sided gallbladder is a rare anomaly. The reported incidence in the population is 0.1-1.2. We present a case of a 32-year male who presented to the surgical unit with a history of right-upper quadrant pain and dyspepsia. Ultrasound abdomen showed normal sized gallbladder with multiple stones. The patient was planned for laparoscopic cholecystectomy. Under general anaesthesia, a supraumbilical port was made and a pneumoperitoneum was created. On introducing the telescope, the gallbladder was found on the left side of the falciform ligament under the left lobe of the liver (segment III). The liver was normal, and there were no adhesions or traction on the gallbladder causing dislocation and thus false impression of left-sided gallbladder. The epigastric port was made on the left of the falciform, rest of the two ports were made as usual. The cystic duct was found to arise from the right side of the right hepatic duct and pass in front of the right and left ducts' confluence to join the gallbladder. The gallbladder was pushed superiorly, and dissection in Calot's triangle was done. The cystic duct and artery were clipped and the gallbladder dissected off its fossa, and haemostasis was secured.

Case Reports and Surgical Strategy Analysis of Laparoscopic Cholecystectomy for Left-Sided Gallbladder

Right-sided ligamentum teres (RSLT) is often associated with portal venous anomalies (PVA) and is regarded as a concerning feature for hepatobiliary intervention. Most studies consider RSLT to be one of the causes of left-sided gallbladder (LGB), leading to the hypothesis that LGB must always be present with RSLT. However, some cases have shown that right-sided gallbladder (RGB) can also be present in livers with RSLT. To highlight the rare variation that RSLT may not come with LGB and to determine whether ligamentum teres (LT) or gallbladder location is reliable to predict PVA. This study retrospectively assessed 8552 contrast-enhanced abdominal computed tomography examinations from 2018 to 2021 [4483 men, 4069 women; mean age, 59.5 ± 16.2 (SD) years]. We defined the surrogate outcome as major PVAs. The cases were divided into 4 subgroups according to gallbladder and LT locations. On one hand, we analyzed PVA prevalence by LT locations using gallbladder location as a controlled variable (n = 36). On the other hand, we controlled LT location and computed PVA prevalence by gallbladder locations (n = 34). Finally, we investigated LT location as an independent factor of PVA by using propensity score matching (PSM) and inverse probability of treatment weighting (IPTW). We found 9 cases of RSLT present with RGB. Among the LGB cases, RSLT is associated with significantly higher PVA prevalence than typical LT [80.0% vs 18.2%, P = 0.001; OR = 18, 95% confidence interval (CI): 2.92-110.96]. When RSLT is present, we found no statistically significant difference in PVA prevalence for RGB and LGB cases (88.9 % vs 80.0%, P > 0.99). Both PSM and IPTW yielded balanced cohorts in demographics and gallbladder locations. The RSLT group had a significantly higher PVA prevalence after adjusted by PSM (77.3% vs 4.5%, P < 0.001; OR = 16.27, 95%CI: 2.25-117.53) and IPTW (82.5% vs 4.7%, P < 0.001). RSLT doesn't consistently coexist with LGB. RSLT can predict PVA independently while the gallbladder location does not serve as a sufficient predictor.

Aberrant gallbladder beneath the left liver is a rare congenital anomaly that is found in 0.1-0.7 per cent of the population. A 24-year-old female complaining about pain in her right upper abdomen with nausea and flatulent dyspepsia. There was no history of fever, jaundice and Liver function tests were normal. The ultrasound of the liver showed a simple lithiasic gallbladder without precising its location, although its insertion was evident to the left of the falciform ligament (A). A laparoscopic cholecystectomy was planned and peroperatively we found an abnormal location of the gallbladder under the left side of the liver (B). An anterograde cholecystectomy was performed without resorting to intraoperative cholangiography. The postoperative consequences were normal. Left-sided gallbladders have been associated with anomalies of the portal vein, the biliary tract and atrophy of segment IV. Many studies suggest performing cholecystectomy normogradely in order to obtain an optimal view of Calot´s triangle. In addition, he found that a subxiphoid port to the left of the round ligament facilitated manip-ulation of the gallbladder, allowing to relocate the gallbladder to the right of the common bile duct. On the other hand, others suggested the use of the antegrade approach in order to well visualize the structures.

Abstract Aim The aim of this project was to examine world literature to establish the various types and frequencies of anatomical variants within the extrahepatic biliary tree, thereby contributing to the body of information available to anatomists, surgeons, and radiologists. Knowledge of the notoriously variable anatomy of the extrahepatic biliary tree is of greater importance than ever, given the increased occurrence and complexity of hepatobiliary and laparoscopic surgeries. Method A database search of MEDLINE, EMBASE and PubMed was conducted in June 2021 and returned 3440 articles, of which 29 were deemed eligible for inclusion. Results A rare malposition, the left-sided gallbladder, was observed in 0.04–0.60% across five studies. A normal cystic artery origin, that is, from the right hepatic artery was observed in 73.3–92% with variations being seen from the left hepatic artery (1–1.9%), gastroduodenal artery (1–7.5%) and the aberrant right hepatic artery (3–12.1%). It was also noted that in 3.6–32% of subjects the course of the cystic artery lay extraneous to Calot's triangle. Michels’ and Hiatt's classification systems were used to define the anatomical variations of the hepatic arteries: studies using Michels’ Type III reported a prevalence from 6.4–15%, Michels’ Type VI from 0.6–7% and Hiatt's Type III recorded an incidence ranging from 9.7–14.8%. Conclusion The most obvious finding to emerge from this project was the widely variable anatomy of the extrahepatic biliary tract and the contrasting reported data. Surgeons should therefore anticipate such complexities and adapt techniques to avoid biliary and arterial injuries and associated intra- and postoperative complications.

Left or right is right? Ectopic gallbladder

S1523 A Case of Ectopic Liver With a Left-Sided Gallbladder

Left-sided gallbladder (LSGB) is a rare congenital anomaly in the gallbladder, which is defined as a gallbladder located on the left side of the falciform ligament without situs inversus. We retrospectively analyzed 13 patients diagnosed with LSGB in a single center to confirm the safety of laparoscopic cholecystectomy (LC) and reviewed the anatomical implications in those patients. Of the 4910 patients who underwent LC for the treatment of gallbladder disease between August 2007 and December 2019, 13 (0.26%) were diagnosed as having LSGB. We retrospectively analyzed these 13 patients for general characteristics, perioperative outcomes, and other variations through the perioperative imaging workups. All patients underwent LC for gallbladder disease. In all cases, the gallbladder was located on the left side of the falciform ligament. The operation was successfully performed with standard four-trocar technique, confirming "critical view of safety (CVS)" as usual without two cases (15.4%). In one case, which had an intraoperative complication and needed choledochojejunostomy because of common bile duct injury, there was an associated variation with early common bile duct bifurcation. The other patient underwent an open conversion technique because of severe fibrosis in the Calot's triangle. Furthermore, on postoperative computed tomography, abnormal intrahepatic portal venous branching was found in all cases. Although LSGB is usually encountered by chance during surgery, it can be successfully managed through LC with CVS. However, surgeons who find LSGB have to make efforts to be aware of the high risk of bile duct injury and possibility of associated anomalies.