Emergency Laparoscopic Cholecystectomy for Acute Cholecystitis with Hepatic Segment 4 Hypoplasia and...

Hepatic hypoplasia and accessory liver tissue are rare congenital anomalies, and their coexistence with acute cholecystitis is exceedingly uncommon. We report a case of acute cholecystitis in a patient with segment 4 hypoplasia and an accessory liver attached to the gallbladder serosa in whom laparoscopic cholecystectomy was performed safely.

A 76-year-old woman presented with acute cholecystitis. CT revealed marked hypoplasia of hepatic segment 4 accompanied by mild hypoplasia of the anterior hepatic segment. Because the intestinal tract was positioned anterior to the gallbladder, percutaneous transhepatic gallbladder drainage was considered difficult, and emergency laparoscopic cholecystectomy was undertaken. Intraoperatively, the gallbladder was displaced to the right, and the duodenum overlapped the gallbladder neck ventrally. These anatomic relationships initially limited visualization and raised concern regarding the need to convert to open surgery. However, adequate exposure was obtained by retracting the lateral hepatic segment to the left using a fan-shaped retractor, placing the patient in the reverse Trendelenburg position, and caudally retracting the duodenum with forceps. With these adjustments, laparoscopic cholecystectomy was completed safely. On the serosal surface of the gallbladder, a reddish-brown mass connected to the liver by a cord-like structure was identified and excised en bloc using energy devices. Histopathological examination confirmed the mass to be accessory liver tissue. The patient's postoperative course was uneventful.

Because accessory liver tissue may contain portal structures and can occasionally harbor malignancy, resection using energy devices is advisable. This case highlights the importance of careful preoperative imaging, meticulous intraoperative anatomical assessment, and appropriate technical modifications when managing patients with rare congenital hepatic anomalies. Surgeons should be aware that such anomalies can alter hepatobiliary anatomy, restrict therapeutic options, and increase operative complexity, necessitating adaptable operative strategies.