PMC6610679_01
A) Surgeon and Trocar position; B) Image of left side gallbladder with, white arrow: round ligament; blue arrow: left lobe; green arrow: gallbladder attached to left lobe; yellow arrow: right lobe at the umbilical fossa; C) Complete dissection of the gallbladder with visualisation of cystic duct (green arrow) and cystic artery (red arrow); D) Safe clipping and section of the cystic artery (red arrow) and cystic duct (green arrow) visualised on the right side of the common bile duct.
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Standard trocar positions were used (Fig. 1A) without any variation of technique, simply following the Strasberg criteria for safe cholecystectomy. Having seen the anatomical variation (Fig. 1B), a careful dissection of Calot's triangle was carried out, the cystic duct and artery were identified and isolated, and subsequent complete dissection of the gallbladder from the liver was done (Fig. 1C). Furthermore, a safe clipping and transection of the cystic duct and artery was achieved (Fig. 1D), and the gallbladder was extracted in an endobag.
CT scan : gallbladder between left lobe and right lobe.
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This was probably due to the presence of a hypertrophic left lobe mimicking only a contiguity with the gallbladder, which itself appeared to be in a physiological position (Fig. 2).
Three-dimensional reconstruction of the portal system: white arrow left portal branch; Black arrow: right posterior portal branch; absence of the branch for the right anterior sector between the two arrowed branches.
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A vascular and biliary reconstruction was then evaluated with evidence of agenesis of the right anterior sector of the liver (Fig. 3) with the absence of the right hepatic duct and an intrahepatic variation with insertion of the right inferior sectorial duct into the left common duct (Fig. 4) as type A3 of Huang Classification.