T. T. Jayakrishnan1, M. Chimukangara1, T. P. Webb1, C. S. Davis1 1Medical College Of Wisconsin,Division Of Trauma, Critical Care, And Acute Care Surgery,Milwaukee, WI, USA
Introduction: Cholecystectomy for gallbladder disease is a common general surgery procedure. A “culture of safety in cholecystectomy” has been proposed to minimize bile duct injuries. However, the proposed culture fails to incorporate careful scrutiny of pre-operative imaging and laboratory analysis, as well as how to address unusual pathology.
Methods: We present three interesting cases of unusual gallbladder anatomy and pathology and propose an algorithm for a safe cholecystectomy that extends beyond aberrant biliary anatomy and the critical view of safety.
Results: With a prevalence less than 0.3%, a truly left-sided gallbladder is a rare anomaly that may provide a surprise during cholecystectomy if not identified pre-operatively. Intra-operative identification may necessitate modification of standard technique, assessment for possible vascular anomalies, and the addition of adjuncts such as intra-operative cholangiogram. Surgery can be performed safely in most cases without conversion to open technique. Similarly, foci of gallbladder wall calcification and the post-operative finding of ectopic pancreatic tissue in the gallbladder wall may lead to management dilemmas, especially when associated with other confounding factors such as elevated tumor markers. Our review of the literature identified no algorithm that incorporates pre-operative imaging, laboratory analysis, or expert consultation in the event that the atypical gallbladder is encountered.
Conclusion: Careful review of pre-operative imaging and laboratory results are critical to a safe treatment plan for patients with gallbladder pathology. Similarly, expert consultation in the event of atypical gallbladder pathology should be liberally entertained. In addition to safe surgical technique, these factors enhance the culture of safety in cholecystectomy and should be incorporated into an algorithm useful for both teaching and clinical purposes.