Agenesis of the Gallbladder With Hypoplastic Cystic Duct Diagnosed at Laparoscopy

Abstract

An 86-year-old man was admitted to our department with complaints of intermittent upper abdominal pain. Ultrasonography of the abdomen showed dilated extrahepatic bile ducts containing stones; however, the gallbladder was not clearly identified. Magnetic resonance cholangiopancreatography showed dilated extrahepatic ducts and choledocholithiasis without gallbladder visualization. The stone extraction was performed with endoscopic sphincterotomy. Three-dimensional images using spiral-computed tomography after intravenous-infusion cholangiography clearly demonstrated an obstruction of the cystic duct. The patient was scheduled for laparoscopic cholecystectomy. At laparoscopy, the gallbladder fossa was not identified on the undersurface of the liver. Despite a thorough examination of the intrahepatic (left-sided within the lesser omentum), retroperitoneal, retrohepatic (within the falciform ligament), retroduodenal, and retropancreatic areas using laparoscopic ultrasonography, the gallbladder was not found. After careful dissection of the hepatoduodenal ligament, the dilated extrahepatic bile duct and a 1-cm length of hypoplastic cystic duct were found. Gallbladder agenesis is usually accompanied by the lack of the cystic duct. The present case is the third report of gallbladder agenesis with a patent or hypoplastic cystic duct.

Congenital Agenesis of the Gallbladder with the Hypogenetic Cystic Duct Definitely Diagnosed by Peroral Cholangioscopy

“…Based on the criteria, some authors stressed the need of thorough surgical exploration [4], exploratory laparotomy with intraoperative cholangiography [18], or laparoscopy combined US [6]. In the present case, CT and MRCP failed to depict the entopic or ectopic gallbladder and ERC demonstrated no entopic or intrahepatic gallbladder but the dilated extrahepatic bile duct with an incompletely developed blind duct in the mid bile duct, which appeared to be the rudimentary cystic duct.…”

Isolated Gall Bladder Agenesis – A Rare Case

“…(4) Gallbladder agenesis (GA) is a rare congenital anomaly characterized by the absence of the gallbladder in conjunction with a normal bile duct system. (5) It can be observed in both children and adults, with a median age of 46 years at the time of diagnosis. It is almost always an incidental finding of the abdominal surgery or a finding at autopsy.…”

“…(5) It has previously been suggested that the pathophysiology of symptoms in gallbladder agenesis is similar to that of the postcholecystectomy syndrome, and it is thought that the causes of pain include biliary dyskinesia and choledocholithiasis.…”

“…In fact, lots of ''laparoscopic'' diagnoses are reported in the literature. 2,5 If the diagnosis of GA is made during operation, the surgeon must prove GA by examining the most common sites for ectopic gallbladder and it is suggested to abort the procedure rather than complete further exploration. Abdominal ultrasound has a reported sensitivity of 95% in diagnosing gallstones but it is dependent on many factors, including the operator's experience and the examination conditions.…”

“…9 Effectively a small, contracted (shrunken, scarred, sclerotic, or atrophied) gallbladder associated with stones and chronic cholecystitis will be difficult to visualize and US scan is highly operator dependent. (3,5) Significant progress in radiology and widespread availability of non-invasive imaging techniques such as computed tomography has taken place in the last few years. However, non-visualization of the gallbladder is commonly attributed to an obstructed cystic duct, anatomic variations, or technical errors (as in our case), and agenesis of the gallbladder is considered the least likely explanation.…”