Page 73 - World Journal of Laparoscopic Surgery

Left-sided Gallbladder
Various technical modifications to laparoscopy have been
reported for successful and safe completion of the procedure. They
include placing the right-hand epigastric port to the left of the
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midline, inserting the right-hand port after evaluation of the GB
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with the left-hand port for proper triangulation, mirror image setup
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of the ports, tilting the table so that the left side of the patient is
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up, using additional ports, clipping the cystic duct as close to the
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infundibulum as possible, fundus-first approach where the Calot’s
anatomy is not clear or dissection is unsafe, and finally, conversion
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to open surgery for safe completion of the procedure. Thus,
with some technical modifications, it is possible to complete the
procedure by laparoscopic means. However, safety is paramount,
and a low threshold for conversion should be maintained at all times.
conclusion
Left-sided GB is a rare anomaly, most often detected intra-
Fig. 1: Intraoperative photograph, GB dissected off the bed from the operatively. The use of an additional port and the fundus-first
undersurface of the segment 3 of the liver (long arrow) by “fundus-first” approach helped in successful laparoscopic completion of the
technique. The falciform ligament (short arrow) is to the right of the GB procedure.

is a variant of aberrant GB. It can be associated with situs inversus. orcid
In the absence of situs inversus, left-sided GB could either be a true
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left-sided GB or an apparent left-sided GB. True left-sided GB is one Srikanth Gadiyaram https://orcid.org/0000-0001-6676-2030
where the GB is in the undersurface of segment 3, and the falciform Murugappan Nachiappan https://orcid.org/0000-0001-8687-3096
ligament is to the right of it. Whereas in an apparent left-sided GB,
GB remains attached to the undersurface of segment 4, but because references
of the relative shift in the position of the round ligament to the 1. Nagai M, Kubota K, Kawasaki S, et al. Are left-sided gallbladders
right, it is identified as a left-sided GB. True left-sided GB is more really located on the left side? Ann Surg 1997;225(3):274–280. DOI:
commoner, constituting around 83% of 55 patients reviewed in a 10.1097/00000658-199703000-00006.
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study by Abongwa et al. The reported incidence of true left-sided 2. Abongwa HK, De Simone B, Alberici L, et al. Implications of
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GB is 0.04–1.1% of the cases undergoing cholecystectomy. left-sided gallbladder in the emergency setting: retrospective
Preoperative diagnosis of left-sided GB is more of a serendipity review and top tips for safe laparoscopic cholecystectomy. Surg
than a norm. Over 80% of the left-sided GBs are identified for Laparosc Endosc Percutan Tech 2017;27(4):220–227. DOI: 10.1097/
SLE.0000000000000417.
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the first time during surgery. Lee et al. reported that, despite 3. Printes TRM, Rabelo ÍEC, Cauduro JF, et al. Left-sided gallbladder
repeated investigation, eight out of ten patients were diagnosed (LSG) associated with true diverticulum, a case report. AME Case Rep
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with surgery. In cases where a preoperative diagnosis is made, 2020;4:26. DOI: 10.21037/acr-20-55.
a thorough evaluation with contrast-enhanced triple-phase 4. Wong LS, Rusby J, Ismail T. Left-sided gall bladder: a diagnostic
computed tomography of the abdomen and a magnetic resonance and surgical challenge. ANZ J Surg 2001;71(9):557–558. DOI:
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cholangiography is appropriate. This helps in identifying any 10.1046/j.1440-1622.2001.02195.x.
variation in the vascular and biliary anatomy of the liver. 5. Lee DH, Kim D, Park YH, et al. Clinical significance and characteristics
Several variations in the anatomy are noticed in the patients of left-sided gallbladder: case series study of 10 patients. Ann Surg
Treat Res 2019;97:302–308. DOI: 10.4174/astr.2019.97.6.302.
with left-sided GB. These have implications whether the patient is 6. Zoulamoglou M, Flessas I, Zarokosta M, et al. Left-sided gallbladder
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undergoing a simple cholecystectomy or a complex liver resection. (Sinistroposition) encountered during laparoscopic cholecystectomy:
Cystic-duct insertion could be into the common bile duct (CBD) or a rare case report and review of the literature. Int J Surg Case Rep
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the left hepatic duct (LHD) based on the embryological pattern. In 2017;31:65–67. DOI: 10.1016/j.ijscr.2017.01.011.
a normal GB bud, which migrates and gets attached to the left liver, 7. Nagendram S, Lynes K, Hamade A. A case report on a left-sided
the cystic duct opens into the CBD. Whereas, failure of development gallbladder: a rare finding during cholecystectomy. Int J Surg Case
of a right-sided GB along with a GB bud developing from the left side Rep 2017;41:398–400. DOI: 10.1016/j.ijscr.2017.11.004.
is associated with cystic duct opening into the LHD or the left side 8. Saafan T, Hu JY, Mahfouz AE, et al. True left-sided gallbladder: a case
report and comparison with the literature for the different techniques
of the CBD. This variation is associated with atrophy of the right lobe of laparoscopic cholecystectomy for such anomalies. Int J Surg Case
of the liver. Apart from this, there are several variations reported in Rep 2018;42:280–286. DOI: 10.1016/j.ijscr.2017.12.029.
the portal venous, hepatic venous, and hepatic arterial anatomies. 9. Idu M, Jakimowicz J, Iuppa A, et al. Hepatobiliary anatomy in
Lee et al. reported the aberrant anatomy that is commonly seen with patients with transposition of the gallbladder: implications for safe
the right branches of the portal vein and the hepatic veins in these laparoscopic cholecystectomy. Br J Surg 1996;83(10):1442–1443. DOI:
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patients. Similarly, the biliary tree also is shown to have aberrant 10.1002/bjs.1800831037.
anatomy, including duplication and hypoplasia, in patients with 10. Zografos GC, Lagoudianakis EE, Grosomanidis D, et al. Management
left-sided GB. Bile duct injury is reported in 7% of patients with left- of incidental left-sided gallbladder. JSLS 2009;13(2):273–275. PMCID:
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sided GB. Therefore, a clear understanding of the arterial, venous 11. Velimezis G, Vassos N, Kapogiannatos G, et al. Left-sided gallbladder in
anatomy, and the biliary tree is critical before any major biliary or the era of laparoscopic cholecystectomy: a single-center experience.
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