Gallbladder fossa volume decreased in livers without gallbladders: A cadaveric study

The gallbladder normally lies within a fossa on the visceral surface of the liver. The primary purpose of this study was to determine whether the volume of this fossa was reduced after cholecystectomy. Livers were obtained from embalmed cadavers of 19 females and 15 males with a mean age of 84.1 ± 10.8 yrs. The presence of a gallbladder was assessed, the volume of the irregularly-shaped gallbladder fossa determined from a mold of the fossa, and the dimensions of each fossa were estimated. The mean volume of gallbladder fossae from livers with gallbladders (n = 26; 13 females and 13 males) was 31.01 ± 17.82 ml, which was significantly greater than fossae in livers without gallbladders (n = 8, 6 females, 2 males) which was 8.75 ± 4.72 ml (P<0.0001). This difference still was significant after correcting fossa volume for overall liver weight and length of the femur. Livers with gallbladders had significantly larger dimensions (depth, length, and width) of their fossae molds than did livers without gallbladders (P<0.05). The largest percentage difference between the two groups in these dimensions was in the fossae depth, and there was a significant, positive correlation between all three of these dimensions and the overall volume of the fossae. Even looking only at female livers which tend to be smaller, gallbladder fossa volume was reduced in livers without a gallbladder. Thus, the present study demonstrated that the mean gallbladder fossa volume was significantly decreased in livers lacking gallbladders, even after correcting for the liver weight and size of the individual. While the mechanisms behind these changes in fossa volume currently are unknown, alterations in mechanical pressure relayed to adjacent liver cells after gallbladder removal may play a role in these fossa volume differences.

Unusual cause of gas complicating a biloma, postcholecystectomy

A 50-year-old man presented to the emergency department with abdominal pain, vomiting and fever. He had been admitted 6 months ago with acute cholecystitis when he underwent endoscopic retrograde cholangiopancreatography (ERCP) to remove ductal gallstones. Elective cholecystectomy was performed 3 days prior to the current admission. CT demonstrated a fluid and gas containing collection in the gallbladder fossa, biliary gas and free intra-abdominal gas. ERCP revealed a retained common bile duct gallstone and leakage from the cystic duct remnant. We postulate that the gas within the collection originated from intrahepatic gas post-ERCP or from a gas forming organism. The free intra-abdominal gas originated from the collection rather than an intraoperative bowel injury. This complicated case highlights an unusual appearance of a common complication. It demonstrates the importance of discussion with the clinical team to ensure that an accurate diagnosis is made and the correct treatment is provided.

Mistaken identity: an unexpected case of spontaneous cholecystocutaneous fistula formation

We describe the case of a 78-year-old woman who presented to the emergency department with a 2-week history of a superficially developing mass in the lower right abdominal wall, fluctuant and non-tender with overlaying erythematous skin changes. Though resembling an abdominal wall abscess and initially listed for a simple incision and drainage, diagnostic uncertainty encouraged further investigation. CT and ultrasound confirmed the mass appeared to be in continuity with the gallbladder fossa, with the lumen also containing small bowel medially. While awaiting a multidisciplinary team discussion, the patient re-presented with concern over discharge appearing at the site of the mass. On inspection, we noted black flecks and small stones. This case describes the unusual and rare presentation of a cholecystocutaneous fistula. The patient was managed conservatively and remains clinically well.

A prospective observational study: combined irrigation of bupivacaine at the gallbladder fossa with infiltration at port site for postoperative pain relief after laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy is a well-established procedure for gallbladder disease. Pain in laparoscopic cholecystectomy is associated with multiple factors: somatic, visceral, and phrenic nerve irritation. Effective analgesic support should, therefore, be a multimodal approach following laparoscopic surgery for better patient compliance.Methods: A prospective, randomized observational study was undertaken at a tertiary research center for a period of two years (2018-2020). 160 patients undergoing laparoscopic cholecystectomy were chosen and randomized using a computer program into 2 groups. No infiltration was given in the control population. The study group was irrigated with a 0.5% bupivacaine solution (20cc in 30 ml normal saline).Results: The bupivacaine group required fewer analgesics in comparison to the control faction, with less pain at 6 hrs. The timing of oral intake and ambulation were comparable in both factions.Conclusions: Combined bupivacaine use led to a considerable decrease in postoperative pain thereby leading to decreased analgesic use.

A 61-year-old Female with Right Upper Abdominal Pain

Case Presentation: A 61-year-old female presented to the emergency department with right upper quadrant abdominal pain following a cholecystectomy 18 days prior. Computed tomography (CT) of her abdomen demonstrated a large abscess in her post-hepatic fossa. She was admitted to the general surgery service and received an image-guided percutaneous drain placement with interventional radiology with immediate return of purulent material. She was discharged home after a three-day hospital course with outpatient antibiotics and follow-up. Discussion: Patients may have multiple complications following cholecystectomy, including infection, bleeding, biliary injury, bowel injury, or dropped stone. The emergency clinician must consider cholecystectomy complications including gallbladder fossa abscess in patients presenting with abdominal pain in the days to weeks following cholecystectomy, especially if they present with signs of sepsis. Critical actions include obtaining CT and/or ultrasonography, initiating broad spectrum antibiotics, and obtaining definitive source control by either surgery or interventional radiology.

Ectopic Gallbladder: An Incidental Finding

Ectopic gallbladder is a rare entity with an incidence of 0.1%- 0.7% [1]. Normally, it lies on the gallbladder fossa, on the inferior surface of the liver in between the right and left hepatic lobes, maintaining a constant relationship to porta hepatis [2]. On Ultrasonographic imaging, the gallbladder can be identified by the relationship of the gallbladder neck anterior to the right branch of the portal vein. Ectopic gallbladder can be located in various positions such as intrahepatic, within the lesser omentum, retroduodenal, within falciform ligament, abdominal wall muscles and in thoracic cavity [3, 4]. An ectopic gallbladder is a dangerous entity as it can lead to misdiagnosis. We were presented a case of ectopic gallbladder, which was missed in ultrasound, and CT scan report but was discovered intra operatively during laparoscopic cholecystectomy

Incidental finding of adenocarcinoma in a gallbladder lumen with no wall involvement

Gallbladder cancer (GBC) is a rare disease characterized by its aggressiveness. Resection with free tumour margins is the sole curative treatment and, in incidental findings, surgical reapproach is recommended for segmentectomy IVb and V or wedge resection of the gallbladder fossa and lymphadenectomy. Here we report a case of gallbladder adenocarcinoma as an incidental finding in a fragment in its lumen with no wall involvement evidentiated. The patient was reoperated for resection of the gallbladder bed with hepatic hilum and cystic duct lymphadenectomy, later evidentiated as free of residual disease. The normality of the bile ducts evidenced by imaging studies, in addition to signs of chronic cholecystitis corroborate to GBC diagnosis. We suspect that the fragment was detached gallbladder polypoid neoplastic lesion. Despite the lack of clinical manifestations, the fast surgical interventions and the histopathological analysis of the material was probably a prognostic determinant for the patient.