Introduction
Chronic cholecystitis due to gallstones is one of the most common biliary pathology. In some cases of chronic cholecystitis, due to recurrent attacks of inflammation and fibrosis, gallbladder begins to contract and in rare cases present as a very small, shrunken gallbladder called micro-gallbladder. By definition, micro-gallbladder is less than 2-3 cm long and 0.5-1.5 cm wide [
1]. Micro-gallbladder can also be seen in some medical conditions like cystic fibrosis, idiopathic neonatal hepatitis and alpha-1 antitrypsin deficiency etc [
2]. Though laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallbladder disease, in cases of micro-gallbladder, it may prove difficult or sometimes infeasible due to obliterated Calot’s triangle anatomy and difficulty in separating such gall bladders from the liver bed.
Case Report
A 45 year female was admitted to our hospital with clinical features suggestive of gallstone disease for the past few months. Her routine laboratory investigations including liver function tests were normal. Abdominal ultrasonography revealed a small gallbladder with multiple stones in its lumen. She was planned for elective laparoscopic cholecystectomy. During laparoscopy, the GB was hidden in the liver bed and was hardly visible. Also there was extensive adhesions present between the inferior surface of liver with colon and omentum. Laparoscopic dissection appeared infeasible due to dense adhesions obliterating Calot’s triangle with concomitant increased risk of iatrogenic injury to biliary and portal structures. Due to this reason it was decided not to continue with laparoscopic dissection and conversion to open procedure was considered.
Operative findings after open exploration were adhesions present between the inferior surface of liver, colon and omentum and small contracted GB embedded in the liver bed with dilated cystic duct and prominent comman bile duct (CBD) [Fig.1]. Since the anatomy of the Calot’s triangle was not very clear, cholecystectomy was done by fundus first method. The GB specimen measured 2.4x1.4 cm and the wall was diffusely thick [Fig.2]. Histopathological examination of GB revealed chronic cholecystitis with cholelithiasis. On the third post-operative day, the patient was discharged from our hospital in stable condition. She is asymptomatic at 3 months follow up.
Discussion
Gallstones are the most common biliary pathology. The etiology of gallstones is probably a combination of defect in lipid metabolism and supersaturation of bile contents, especially cholesterol. Chronic cholecystitis is a long standing GB inflammation almost always resulting from gallstones and prior episodes of acute cholecystitis. Damage results from infiltration of chronic inflammatory cells leading to a fibrotic and shrunken GB, which in rare cases may present as very small and shrunken GB, called as micro-gallbladder [
1]. Micro-gallbladder is defined as a GB with less than 2-3 cm length and 0.5-1.5 cm width. Beside chronic cholecystitis, micro-gallbladder is also seen in some medical conditions like cystic fibrosis, idiopathic neonatal hepatitis and alpha-1 antitrypsin deficiency [
2]. Diagnosis of this condition is suspected by ultrasound having evidence of small contracted gallbladder, but is confirmed on table by per-operative findings.
Laparoscopic treatment is the gold standard treatment for symptomatic gallstone disease presently. Micro-gallbladder is a challenge for laparoscopic surgeons [
3,
4]. The initial fundus grasping is difficult. The loss of tissue plane is also a problem because of repeated attacks of inflammation. Thick walled gallbladder is a problem for assistant to hold and retract the gall bladder. At times, dense adhesions between inferior surface of liver with colon and omentum leads to almost non-visualization of gall bladder. Many of these cases have very small cystic duct which is difficult to ligate or clip. In presence of difficult anatomy and inability to pull gallbladder to dissect the Calot’s triangle, there is definite risk of injury to biliary and portal structures [
5]. In such cases hydro-dissection with suction cannula is advisable and if there is no progress in dissection of Calot’s triangle, conversion to open procedure is recommended [
6]. Conversion to open cholecystectomy in these cases should be considered neither a failure nor a complication of procedure, but an attempt to avoid complication.
Conclusion
It is emphasized that micro-gallbladder is a definite entity and usually diagnosed per-operatively on table. Micro-gallbladder is a challenge for laparoscopic surgeons and if difficulty is encountered during dissection, early conversion to open procedure is recommended.
References
- Wang DQH, Afdhal NH. Gallstone diseases. In: Sleisenger and Fordtran’s Gastrointestinal and Liver Diseases, 9th ed. Philadelphia, Saunders Elsevier; 2010;65:1126-1136.
- Shehadi WH. The biliary system through ages. Int Surg. 1979;64:63-73.
- Glenn F, Grafe WR. Historical events in biliary tract surgery. Arch Surg. 1966;93:848-854.
- De U. Evolution of cholecystectomy: A tribute to Carl August Langenbach. Indian J Surg. 2004;66:97-100.
- Kama NA, Kologlu M, Doganay M, Reis E. A risk score for conversion from laparoscopic to open cholecystectomy. Am J Surg. 2001;181:520-525.
- Nduka CC, Super PA, Monson JR, Darzi AW. Causes and prevention of electrosurgical injuries in laparoscopy. J Am Coll Surg. 1994;179:161-170.