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Ghaderi et al. Mini-invasive Surg 2018;2:13 I http://dx.doi.org/10.20517/2574-1225.2017.52 Page 3 of 5

patient’s pain resolved spontaneously and he was discharged home. Another episode of RUQ pain with
nausea developed three months later, with radiation of the pain to his back. He also had jaundice, light-
colored stools, and nausea. The patient again visited his local emergency department, where his bilirubin
was 9.1 mg/dL. Subsequently, a RUQ ultrasound and MRCP verified duplicated gallbladder and now
showed cholecystitis of the medial gallbladder. The common bile duct was dilated to 7.9 mm in diameter.
An ERCP with sphincterotomy was performed and two tiny stones were retrieved. A biliary stent for
stricture at the distal common bile duct was placed. The patient was transferred to our tertiary center for
further management.

At our institution, a second ERCP was performed to further assess the common bile duct for a possible
malignancy. In this study, no stricture was seen and the biliary stent was removed. Subsequently, he was
taken to the operating room for laparoscopic cholecystectomy.

The operation was started by taking down omental adhesions and dissecting the peritoneum overlying the
medial and lateral aspects of the gallbladders [Video 1]. Due to the extent of the inflammation and aberrant
anatomy, a top-down dissection was then used to mobilize both gallbladders and confirm structures.
During this dissection, the medial gallbladder was inadvertently entered. This decompressed the inflamed
gallbladder and facilitated the rest of the operation. The cystic duct and artery of the lateral gallbladder
were identified, isolated, doubly clipped and divided. Similarly, the cystic artery of the medial gallbladder
was controlled. The medial cystic duct was the only remaining structure entering the gallbladder. Given
the size of duct, it was divided using a stapler.

Postoperatively, the patient’s bilirubin continued to rise. A third ERCP on postoperative day 1 suggested
ampullary edema and intrabiliary clot without evidence of biliary injury. His bilirubin normalized
gradually, and he was discharged home on postoperative day 5.

DISCUSSION
DG is not associated with specific symptoms or even with a predisposition for gallstone formation. As such,
[6,9]
the condition may persist unnoticed or undiagnosed . When symptoms do occur, gallbladder duplication
may go unappreciated due to the rare nature of the anomaly or the insensitivity of diagnostic testing.
Diagnosis of DG may be mistaken for more common problems such as folded gallbladder, pericholecystic
fluid, gallbladder diverticulum, Phrygian cap, vascular band, or focal adenomyomatosis [9,13] .

In the case reported herein, a preoperative CT scan and RUQ ultrasound suggested DG, which was
confirmed with MRCP. It has been suggested that ERCP is the most accurate test in displaying the biliary
[14]
tract anatomy of gallbladder duplications , however ERCP is not indicated for most patients with biliary
[11]
colic due to its invasive nature . In the present case, even though ERCP was performed for evaluation of
the biliary stricture, it did not identify the medial gallbladder with an obstructed cystic duct. Therefore, we
advocate consideration of cross-sectional imaging by CT or MRCP if RUQ ultrasound raises the possibility
of gallbladder duplication.

For a surgeon without preoperative suspicion, certain intraoperative presentations of DG may be more
difficult to recognize than others. Awareness of the variations is helpful. Septations and partial duplications
with one cystic duct, complete duplications within a common peritoneal coat, and intrahepatic duplications
[7]
may go unnoticed if the surgeon is not aware of the abnormalities . When identified preoperatively or
at operation, the literature suggest benefit to removal of all gallbladders at a single operation to prevent
[16]
persistent or recurrent symptoms [3,8,15] . In addition, multiple pathologies may exist. Roeder et al. reported
a case of a triplicated gallbladder, where one had cholelithiasis and cholecystitis, a second had papillary
adenocarcinoma, and a third was intrahepatic without disease. For these reasons, we agree a surgeon

should endeavor to remove all gallbladders.