Duplication of the gallbladder: An intraoperative finding during laparoscopic cholecystectomy

Duplication of the gallbladder is a rare congenital malformation associated with the development of cholelithiasis. It increases the risk of iatrogenic bile duct injury during cholecystectomy and can lead to symptom recurrence if missed. Although preoperative imaging is helpful, detection rates are around 50 %.

A 36-year-old healthy female with symptomatic gallstone disease and ultrasonographic evidence of cholelithiasis was scheduled for elective laparoscopic cholecystectomy. Following standard four port entry and dissection of pericholecystic adhesions to duodenum, a V shaped duplicated gallbladder with calculi, and a common cystic duct and artery was noted. The cystohepatic triangle was dissected, critical view of safety demonstrated and the common cystic duct and artery were divided between clips.

Variations in gallbladder morphology has been described by Gross, Boyden and Harlaftis classification. Type 1 (bilobed gallbladder) has a common embryological origin with an invaginating septum separating the lumens while type 2 (double gallbladder) has a double embryological origin with separate gallbladders and their own cystic ducts. Many cases go undetected or are mis-identified as choledochal cyst, diverticulum or Phrygian cap. MRCP is the imaging modality of choice for suspected duplicate gallbladder.

Careful dissection of the cystohepatic triangle with attention to critical view of safety is important in all cases as numerous variations in hepatobiliary anatomy have been described. Surgical awareness of these variations and good surgical technique will promote safe laparoscopic cholecystectomy even in the most unexpected of encounters.