PMC3021271_01
Ultrasound of Gallbladder. Notice the marked thickness of the gallbladder wall. The twisted pedicle of the gallbladder appears as "septations of the wall" posteriorly.
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F1
An ultrasound of the gallbladder done on the third day of admission showed a thickened gallbladder wall of up to 11 mm, "posteriorly...multiple septations of the gallbladder wall" (Figure 1), and multiple stones.
The twisted gallbladder pedicle leads to a thickened gangrenous gallbladder at its left; The anterior edge of the liver is visible to the right of the pedicle.
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F2
The gallbladder was then grasped at the fundus and retracted cephalad, exposing a twisted gallbladder pedicle (Figure 2).
After reduction of the volvulus, the cystic duct was cannulated for a cholangiogram. Notice the gangrenous changes of the pedicle and the gallbladder beyond the cannulation point of the cystic duct.
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F3
With the gall-bladder pedicle reduced, it was evident that it allowed an unusually high freedom of movement of the gallbladder, which was only partially attached to the liver at the level of the gallbladder neck (Figure 3).
Careful dissection of the cystic duct-common bile duct junction clearly demonstrates the vicinity of the junction to the anterior edge of the liver.
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F4
The pedicle was unusually long with the common bile duct stretched close to the level of the anterior edge of the liver (Figure 4).
The gallbladder bed is visible over the cystic duct and artery stumps along the anterior liver edge. This limited area of the gallbladder attachment served as a point of fixation allowing the gallbladder to twist around it.
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F5
The removal of the gallbladder off the liver bed was easily accomplished by dividing with cautery the limited area of gallbladder attachment to the liver bed (Figure 5).