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KEYWORDS:Left-sided gallbladder;Preoperative diagnosis;Bile duct injury;Intrahepatic portal;Venous and biliarysystems;

uncommon anomaly. The first published account of sinis-1

tography. Although laparoscopic cholecystectomy for

patic portal venous and biliary systems associated with

nperforming any form of partial hepatectomy, including

2,68

A retrospective review was performed on patients with

possible, appropriate radiographs were retrieved and ana-lyzed, together with intraoperative photographs whentaken. The preoperative diagnosis of left-sided gallbladderwas assessed. The details of the operative procedure were

---* Corresponding author. Tel.:161-7-3176-2111; fax:161-7-3176-7011.

The American Journal of Surgery (2013) -, --E-mail address: russell_strong@health.qld.gov.auleft-sided gallbladders can be performed safely,4,5 it wouldappear from the literature that bile duct injury at cholecys-tectomy is not unusual.2,6 Because of the anomalous intrahe-

left-sided gallbladder who were managed by the PrincessAlexandra Hospital hepatobiliary surgeons since 1996. Thepatients were identified by way of unit log books. Whentroposition of the gallbladder was in 1886, and fewer than150 cases have been reported in the literature.2 However,the condition may not be as rare as generally believed,3

and the diagnosis is frequently missed even with ultraso-nography and endoscopic retrograde cholangiopancrea-

4

reduced-size and living-donor liver transplantation.

Patients and MethodsLeft-sided gallbladder is considered to be a very sinistroposition, the implications are considerable wheHepatic resectionManuscript received July 10, 2012; r

2012

0002-9610/$ - see front matter 2013http://dx.doi.org/10.1016/j.amjsurg.20AbstractBACKGROUND: A left-sided gallbladder in a normally positioned liver is considered to be a very

uncommon anomaly. Laparoscopic cholecystectomy can be performed safely, but bile duct injury isnot unusual. It is associated with anomalous intrahepatic portal and biliary systems which impactsany form of partial hepatectomy.

METHODS: We performed a retrospective review of patients with left-sided gallbladder who weremanaged by the hepatobiliary surgeons at our institution since 1996.

RESULTS: Nineteen patients with left-sided gallbladder underwent a hepatobiliary procedure. Of the13 patients with gallstones, only 1 was diagnosed before cholecystectomy. Nine operations werecompleted laparoscopically, whereas 4 required an open procedure. Two patients were referred withbile duct injuries. There was 1 liver resection for a colorectal metastasis. Left-sided gallbladders in3 deceased organ donors resulted in major implications in the performance of liver transplantation.

CONCLUSIONS: Left-sided gallbladders are probably more common than generally believed but arerarely diagnosed before cholecystectomy. Associated bile duct injury appears to be not infrequent.Because of the aberrant vasculobiliary anatomy, any form of liver resection requires careful planning. 2013 Elsevier Inc. All rights reserved.Surgical implications of a le

Russell W. Strong, M.D.*, Jonathan FawcPeter Hodgkinson, M.D., Stephen Lynch,Kellee Slater, M.D., Shinn Yeung, M.D.

Hepatobiliary Unit, Princess Alexandra Hospital, Ipswich Revised manuscript September 10,

Elsevier Inc. All rights reserved.

12.10.035, Woolloongabba, Queensland 4102, Australiasided gallbladder

, M.D., Michael Hatzifotis, M.D.,D., Thomas ORourke, M.D.,scrutinized, and particular attention was paid to the methodof gallbladder removal, either laparoscopically or as an

open operation. In those patients with left-sided gallbladderin whom partial hepatectomy, including reduced-size livertransplantation, was performed or planned, the conse-quences related to the anomalous portal venous and biliarysystems were assessed.

Results

veins between the liver and the inferior vena cava (IVC),

2There were 19 patients with left-sided gallbladders whounderwent surgical procedures (Table 1). Thirteen patientspresented with typical biliary-type pain, and gallstoneswere diagnosed by ultrasonography. However, only1 patient was diagnosed preoperatively as having a left-sided gallbladder, and this was as a result of computedtomography performed for another reason.

Of the 13 patients undergoing cholecystectomy, 9 pro-cedures were successfully performed laparoscopically;1 procedure was converted to an open operation tocomplete exploration and remove a stone in the commonbile duct. Three procedures were converted to openoperations to complete the cholecystectomy. One patientwho had gallstones diagnosed by ultrasonography wasreferred by a surgeon who could not find the gallbladder atopen operation. At reoperation by one of our surgeons(S.L.), the gallbladder could not be found extrahepati-cally, but a hard lump was palpable intrahepatically insegment 3. Opening the liver identified the intrahepaticgallbladder, which was then removed. However, therewere 5 bile ducts draining directly into the gallbladder,and a challenging Roux-en-Y biliary reconstruction of the5 ducts ensued. The patient was well with normal liverfunction 4 years later.

There were 2 patients who sustained bile duct injuryduring cholecystectomy of a left-sided gallbladder at otherinstitutions. They were immediately referred to the hep-atobiliary unit at Princess Alexandra Hospital, and 1 of thesurgeons (J.F.) traveled to these hospitals to perform biliaryreconstruction. The patients have been well since that time.

There was 1 patient with a colorectal liver metastasis,which was originally thought to be in the left hemiliver, butidentification of a left-sided gallbladder led to the realiza-tion that there was an absent segment 4, and a left-sidedresection would necessitate extension into segments 5and 8. This was achieved without any problems.

There were 3 deceased organ donors with left-sidedgallbladders. All donor operations were performed by 1 ofour surgeons (R.S.). The first was in 1997 and was from an

Table 1 Patients with left-sided gallbladder undergoinghepatobiliary surgical procedure

Cholecystectomy 13Biliary reconstruction after bile duct injury elsewhere 2Liver resection for colorectal metastasis 1Donor liver for transplantation 3

Total 19and the major hepatic veins bypassing the IVC andconnected directly to the right atrium. It was decided notto use the liver for transplantation.

Comments

The finding of a left-sided gallbladder signifies a devel-opmental aberration, which may have major consequenceswhen performing cholecystectomy or any form of hepatec-tomy. The vast majority of publications on the subject haveemanated from Asian countries, especially Japan, butwhether the incidence is greater there or is just identifiedwith greater frequency is not known. The reportedincidence of the condition ranges from 0.2% to 1.1%.6 Ina recent publication from the University of Tokyo Hospital,a 3-dimensional reconstruction of the vascular structures ofthe liver among 8,050 consecutive image readings by 1 radi-ologist over a 7-year period found 35 patients (0.4%) whowere incidentally diagnosed.3 Moo-Young et al2 estimatedthat in the United States, between 70 and 100 cases ofleft-sided gallbladder will be seen at laparoscopic cholecys-tectomy each year.

So, how does a left-sided gallbladder come about? Thereis a difference of opinion about origin as well as nomen-clature. Uesaka et al,7 in reporting on 2 patients withleft-sided gallbladders, showed intrahepatic portal venousanomalies. In the fetal period, the intrahepatic portalvenous system develops from the pair of umbilical veins.During development, the left umbilical vein becomes 1 ofadult donor. The intention was to harvest a reduced-sizegraft for a child who was in desperate need of livertransplantation. The intrahepatic vasculobiliary anatomywas confusing, and the procedure would have been aban-doned except for the relative urgency. Within 48 hours oftransplantation, portal vein thrombosis had occurred,necessitating urgent repeated transplantation.

The second donor liver with sinistroposition of thegallbladder was intended to be used as a split liverdtheright side for an adult recipient and the left side for a child.On finding a left-sided gallbladder, the proposition wasabandoned, the surgeon being very aware of the previousexperience. The liver was used purely as a whole liver graftfor an adult. A cholangiogram after transplantation showedthe biliary anatomy, (Fig. 1) which in itself would havemade split liver transplantation extremely difficult, but to-gether with the likely aberrations of the intrahepatic portaland hepatic venous systems,7,8 it was virtually impossible.

The third donor with a left-sided gallbladder was a12-year-old girl who had cardiac arrest outside a majorprovincial hospital. She was resuscitated but became braindead and was an organ donor. She had previously had openheart surgery. At the donor operation, she was found tohave a left-sided gallbladder; a preduodenal portal vein,hepatic artery, and common bile duct; no short hepatic

The American Journal of Surgery, Vol -, No -, - 2013the afferent vessels to the liver, whereas the right umbilical

laddvein atrophies. After obstruction of the left umbilical veinand ductus venosus, the typical umbilical portion to theleft main portal vein is formed. Atrophy of the left umbil-ical vein, with persistence of the right umbilical vein, prob-ably accounts for the anomaly. It can be associated withother anomalies, including a preduodenal portal vein, asidentified in 1 of the liver donors in this series, or azygoscontinuation of the IVC. On occasion, all of these anoma-lies are considered to accompany developmental failureof other intra-abdominal vascular systems.8,9

Nagai et al8 from Japan do not regard it as a left-sidedgallbladder but as a right-sided round ligament, which is as-sociated with abnormal intrahepatic venous branching andhas significant implications during liver resection. Thisconcept is supported by Shindoh et al,3 who concluded

Figure 1 The biliary anatomy.R.W. Strong et al. Surgical implications of left-sided gallbthat it was a right-sided round ligament with anomalousconnection to the right paramedian portal pedicle, wasnot a malposition of the gallbladder, and its origin wascaused by a persistence of the right umbilical vein.

In contrast, Savier et al6 in Paris believe that it is bestunderstood as a failure of development of the medial seg-ment of the left hemiliver, ie, segment 4, and fusion ofthe midplane and left intersectional plane. Further, in a laterstudy using multidetector-row computed tomography with3-dimensional volume rendering reconstruction, the sameauthors were firm in their belief that the abnormality isnot a consequence of the persistence of the right umbilicalvein but the result of defective development of the medialsection of the left hemiliver during embryonic life and,therefore, fusion of the planes.10

Implications for cholecystectomy

This is all somewhat academic for the surgeon who isabout to perform a cholecystectomy and is unexpectedlyfaced with a left-sided gallbladder. Both in the presentseries and from reports in the literature, the preoperativediagnosis of a left-sided gallbladder is rare.2,4,5,11 It is asso-ciated with anomalies of the cystic duct and artery.2,4,12 Thecystic artery originates from the right hepatic artery, whichlies to the right of the common hepatic duct (CHD), alwayspassing from right to left across in front of the CHD to thegallbladder.4 The cystic duct most commonly curls aroundthe CHD to enter it on the right side but may enter the CHDon its left side or, as in 1 case in the present series, enter theleft hepatic duct. The possibility of an anomaly of the bileducts should always be considered when a left-sided gall-bladder is encountered.2

There is no doubt that patients with left-sided gallblad-der can have it successfully removed laparoscopically as inthe present series and as reported in the literature.4,5,13

Although cholecystectomy can be performed with the stan-dard port sites, the best arrangement consists of medial po-sitioning of the gallbladder retracting ports Fig. 2A andplacement of the right-hand operating port well to the leftof the midline. According to Idu et al,4 the most useful sim-ple procedure for improving exposure is the falciform lift,which lifts the central portion of the liver and moves theligament off the operative field Fig. 2B.

It would seem most prudent to perform a retrogradedissection, fundus down, whether laparoscopically or as anopen procedure Fig. 2C. During laparoscopic cholecystec-tomy, the main problem seems to be surgical exposure be-cause of the vicinity of several bile ducts in a limited spaceunder the round ligament, including the hepatoduodenalligament just behind the neck of the gallbladderFig. 2D,E. A cautious laparoscopic approach would seemreasonable, taking into account other local conditionssuch as inflammation, remembering that bile duct injurywould appear to be more likely to occur with a left-sidedgallbladder.2,6 In addition, there is a variable degree towhich the gallbladder is embedded within the liver paren-chyma, which in itself causes technical difficulties. Theextreme end of the spectrum was manifested in 1 case inthis series.

There should be a strong tendency to convert to anopen procedure when there is anatomic uncertainty,particularly when there is marked inflammation. Thegallbladder obscures the hepatoduodenal ligament struc-tures. The inability to dissect and reveal the Calottriangle, as in cholecystectomy of a gallbladder in thenormal position, is almost certainly a contributing factortoward an increased propensity to cause bile duct injury,and awareness of such issues should help avoid this.Perception and orientation are extremely important insurgery, and especially in minimal access surgery, aspointed out in a recent article by Sodergren et al.14 Wayet al,15 in an analysis of 252 cases of laparoscopic bileduct injuries, found the primary error in 97% of caseswas a visual perceptual illusion, leading to operator diso-rientation, and Hugh16 suggested that misidentification ofbiliary anatomy with inadequate extrabiliary reference

er 3points led to disorientation and was a major cause of

4bile duct injury during laparoscopic cholecystectomy. Ifthese parameters are instrumental in such problems dur-ing so-called routine laparoscopic cholecystectomy, thinkof how much more likely bile duct injury is to occur whendealing with a left-sided gallbladder.

Implications for hepatic resection and livertransplantation

Although detailed vascular and biliary anatomy is notnecessary before performing a cholecystectomy, it is abso-lutely essential before performing a partial hepatectomy,including the use of reduced-size grafts for liver transplan-tation. In addition, routine intraoperative confirmation ofthe vascular structures using ultrasonography or a testclamp before ligation of prominent vessels may reducethe risk of anatomic misinterpretation and subsequentsurgical complications.3 Close attention must be paid tothe abnormal branching of the intrahepatic portal vein.When performing a right hemihepatectomy, only the portal

Figure 2 (AE) Laparoscopic cholecysThe American Journal of Surgery, Vol -, No -, - 2013branches that arise from the right umbilical vein and courseto the right should be divided. Ligation of the right portalvein itself results in interruption of portal flow to a portionof the left hemiliver.7,8

What about the use of partial livers for transplantationfrom donors with left-sided gallbladders? There have beensuccessful living donor transplantations, mainly adult tochild, using the left side, but even in these cases technicalmodifications were required, and considerable preoperativeimaging and preparation was necessary.1719 In the settingof deceased donors, who are the main source of organs inWestern societies, this imaging and preparation is not pos-sible, and it would seem most appropriate to use the wholeliver in these circumstances.

Conclusions

In conclusion, left-sided gallbladders are probably morecommon than generally believed. They are rarely diagnosedbefore cholecystectomy. Itwould appear that cholecystectomy

tectomy of a left-sided gallbladder.

is associated with a higher rate of bile duct injury with left-sided gallbladders than when the gallbladder is in its normalposition. Because of the aberrant intrahepatic vasculobiliaryanatomy, any form of liver resection is complex and requirescareful planning.

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R.W. Strong et al. Surgical implications of left-sided gallbladder 5

Surgical implications of a left-sided gallbladderPatients and MethodsResultsCommentsImplications for cholecystectomyImplications for hepatic resection and liver transplantation

ConclusionsReferences