Agenesis of the gallbladder: lessons to learn

Congenital absence of the gallbladder is a rare, usually asymptomatic, anatomical variation. Some affected individuals may present with a clinical picture suggestive of gallbladder disease. This presentation, coupled with the inability of standard abdominal ultrasonography to convincingly diagnose agenesis of the gallbladder, can put the surgeon in a diagnostic and intraoperative dilemma.

A 30-year-old lady presenting with clinical features of cholecystitis and diagnosed with shrunken gallbladder on ultrasonography was scheduled for laparoscopic cholecystectomy. Intraoperatively, the gallbladder could not be seen even after thorough dissection in the region of the porta hepatis. The procedure was terminated at this stage, and further imaging of the extrahepatic biliary system by magnetic resonance cholangiopancreatography and endoscopic ultrasound confirmed the diagnosis of congenital absence of the gallbladder.

Nonvisualization of the gallbladder at laparoscopy, in the absence of any other diagnosed biliary disorder, need not prompt conversion to open exploration of the extrahepatic biliary system. Newer imaging modalities are relatively noninvasive and can provide good delineation of biliary anatomy. This allows wellplanned treatment and at the same time prevents the added morbidity of a diagnostic laparotomy performed solely to confirm the absence of the gallbladder.