Preoperative diagnosis of a double Gallbladder with cholelithiasis in the era of advanced Imaging : a rare case report

Introduction: Double gallbladder is one of the rare congenital anomaly of the gallbladder and a surgeon may come across it once in life time. case Presentation: We present a case of double gall bladder separated by a common wall. this case was neither diagnosed nor suspected by radiologist on routine ultrasound. the patient was reported as a usual case of cholelithiasis and an inoperative surprising rare surgical anomaly of gall bladder was observed. Conclusion: this congenital anomaly can present as a surprise on the operating table and may pose a difficult cholecystectomy.


IntroductIon
Gall bladder anomalies are not that rare but of the list of anomalies reported a double gall bladder is extremely rare and one may come across it once in a life time.We report this case of double gall bladder which came as a surprise to us on operating table.As the disease was not expected preoperatively we had difficulty in performing the so assumed routine and easy abdominal surgery called cholecystectomy.Present literature describes incidence of double gall bladder to be 0.25 per 1000 autopsy series.Two types of double gall bladders known include Type1: having two compartments separated by a membrane with a single cystic duct and Type 2: having two distinct compartments with two cystic ducts.The gall bladder disease can either affect one lobe or both lobes of the double gall bladder.However, both cases require complete surgical removal of the organ.
The anatomical location of a double gallbladder is variable; most gallbladders share a common peritoneal coat and are usually adjacent to each other.Occasionally, one gallbladder could be entirely intrahepatic or even sub-hepatic.True gallbladder duplication can either have a common cystic duct, arterial supply or separate cystic ducts and blood supply.
Timely diagnosis of such congenital anomalies of the gall bladder is extremely important in order to carefully plan the surgical intervention.Although gall bladder surgery is considered to be a routine surgical procedure, patients with congenital anomalies require additional operative care to avoid inadvertent complications as injury to the common bile duct or finding other gall bladder subsequent to the surgery.

dIscussIon
Duplication of the gallbladder is a rare anomaly of the biliary tract, occurring at a rate of 0.25/1,000 in one autopsy series. 1 Embryologically this occurs rarely when the gallbladder primordial bifurcates and results in duplication of gallbladder in 5 th or 6 th week of life.There are a wide range of congenital anomalies of the Gallbladder is noticed and reported in literature ranging from double gallbladder to the complete absence of the gall bladder.
There are two types of double gall bladder: 1. Gall bladder with two adjacent lobes that are separated by a soft membrane -usually having a single common cystic duct; 2. And the other variety that involves the presence of two distinctive, separate organs -that usually have separate ducts  Like present case other authors have also reported different pathology in the two compartments of the Double Gall bladder. 2,3Gallstone is the commonest complication occurring in one or both gallbladders.
There is no increase in the incidence of disease in double gallbladder, so prophylactic cholecystectomy in an asymptomatic patient is not recommended. 4It is important to diagnose this anomaly pre-operatively because the second gallbladder may be overlooked during surgery. 5though in the past these anomalies couldn't be revealed by traditional methods of diagnosis, nowadays it can be easily diagnosed by magnetic resonance imaging, 6 computerized tomography, or even by an ultrasound performed by an experienced radiologist.

conclusIon
We have come across a case of double gallbladder on table as routine ultrasound did not pick up the same.This conveys a message that even in present era of advanced imaging gadgets a double gall bladder may be overlooked and surgeons should keep this entity in mind while performing the so called commonest operation in surgical practice.

Figure 1 : 2 :
Figure 1: Specimen of resected Gallbladder Figure 2: Two lumens of the Double Gallbladder

missed Preoperative diagnosis of a double Gallbladder with cholelithiasis in the era of advanced Imaging: a rare case report Sadaf Ali, Sajjad A Mallik, Omar J Shah Atthar B khan
Introduction: Double gallbladder is one of the rare congenital anomaly of the gallbladder and a surgeon may come across it once in life time.casePresentation: We present a case of double gall bladder separated by a common wall.thiscase was neither diagnosed nor suspected by radiologist on routine ultrasound.thepatient was reported as a usual case of cholelithiasis and an inoperative surprising rare surgical anomaly of gall bladder was observed.Conclusion: this congenital anomaly can present as a surprise on the operating table and may pose a difficult cholecystectomy.Key words: Double Gall bladder, cholelithiasis, imaging, case report