Video of the Month. Laparoscopic Cholecystectomy for Left-Sided Gallbladder and Hepatic Pedicle

Left-sided gallbladder (LSGB) in a normally positioned liver, namely in the absence of situs inversus viscerum, is a very uncommon condition. Its incidence is reported in the literature between 0.004 and 0.3 % . It is rarely diagnosed by ultrasounds and usually represents an unexpected finding during laparoscopic cholecystectomy for stones. Sometimes, the gallbladder is simply located to the left of an abnormally right-sided round ligament and, in this case, it should be defined as “wrong LSGB”. When the gallbladder is really attached to the left lobe of the liver, it should be defined as “ true LSGB”. More rarely, the hepatic pedicle is also located to the left of the round ligament and the cystic duct joins the CBD from the left side. Anomalies of the biliary and vascular anatomy are frequently associated and, consequently, bile ducts injuries appear to be not infrequent in these cases. A 39-year-old female, without previous medical problems, presented with recurrent biliary pain and evidence of stones in the gallbladder at the ultrasonography. Laparoscopic cholecystectomy was planned with the patient in the American position, supine with the left arm in abduction. After insertion of the camera in the umbilical port, the gallbladder was not found in its natural position, but adherent to the left lobe of the liver. The hepatic pedicle was also located to the left of the umbilical fissure with hepatic artery on the its right edge. The operative trocar was positioned in the left hypocondrium rather than in the epigastrium. After identification of the cystic artery, arising from the hepatic artery, and the cystic duct, these structures were clipped and divided. The CBD was clearly identified. The gallbladder was detached from the liver bed and extracted with a bag. The postoperative course was uneventful and the patient was discharged in the first postoperative day.