Left Side Gallbladder: Clinical and Anatomical Implication

*Filippo Banchini and Patrizio Capelli*

#### **Abstract**

Left side gallbladder is a rare anatomical anomaly reported in the literature. It is associated with various anatomical variations of the biliary way and intrahepatic portal supply. Most of the time, it is discovered as an incidental finding during intervention for cholecystectomy, exposing patients and surgeons to high risk of complication. To prevent this, we analyze the critical aspects that must be known to perform safe interventions either in the normal setting or in the emergency setting. Different theories are proposed to describe this anomaly, but a debate is still open. Reviewing the literature and analyzing the different processes of formation, we create a classification that can explain how this anomaly can occur, dividing into four variation types.

**Keywords:** left side, gallbladder, fusion of plans, liver resection, biliary, agenesis, abnormality, cholecystectomy, right umbilical vein, liver, hepatic

#### **1. Introduction**

The left side gallbladder (LSG) is a very rare alteration defined by the attachment of the gallbladder to the left lobe of the liver at the right side of the ligament tears.

Since Hochstetter's first description in 1886 [1], about 150 cases have been reported in the literature. The attempts to explain the cause of this anomaly have been different, but the numerous variations described do not allow a clear definition of its origin. Although this debate is still open, it is of considerable importance to know that LSG is frequently associated with alterations of both the portal branches and the intrahepatic biliary tree. The association of these anomalies, therefore, represents an important risk, especially if surgical treatment is necessary. There are two cases in which surgical treatment may be required: the first is gallbladder stones and in particular acute cholecystitis, and the second is the need for liver resection surgery. In the first case, the diagnosis of gallstones and cholecystitis is made only with ultrasound, but often this method does not describe the anomaly of the LSG. In fact, in most cases described, the diagnosis is made intraoperatively, making the surgical treatment problematic and risky due to the lack of correct anatomical knowledge. In the case of liver resection, the diagnosis is made before surgery, highlighting anatomical variations that require complex dissection strategies. Knowledge of the anomalies associated with a LSG can be of considerable help in preventing serious complications.

#### **2. Estimation incidence and diagnosis**

The real estimation of this anomaly is very difficult because most of the published articles are case reports and only a few of them have high numbers of cases. The literature analysis revealed 114 articles concerning LSG: 89 authors describe 1 case only, 11 present 2 cases, 3 present 3 cases, 3 present 4 cases, 3 describe 6 cases, 1 describes 7 cases, 2 describe 9 cases, 1 describes 10 cases, and 1 describes 26 cases, with a total of 211 cases (**Table 1**).

The incidence is variable and remains always below 0.3%: Idu et al. [109] describe 5 cases of LSG on 1764 cases of cholecystectomy (0.3%), Nagai et al. [90] 3 cases out of 1621 (0.2%), Sadhu et al. [43] 1 out of 1258 (0.08%), and Rozsos et al. [37] 1 out of 2536 (0.04%).

Naganuma et al. [87], in a series of 67.994 patients studied with ultrasound, found 18 cases of abnormal gallbladder position with an incidence of 0.026%. These included retrohepatic, supraphrenic, and floating gallbladder, and only nine cases of LSG, with an incidence of 0.013%. However, ultrasound is not the main exam to make the diagnosis. Pereira et al. [115] show that ultrasound has a positive predictive value of only 2.7% and that in 81.1% LSG is initially detected at surgery. Also, Lee et al. [36], in his series of 10 cases operated on for cholecystic stones or acute cholecystitis symptoms, describes the discovery: intraoperative in 8 cases and as an incidental finding on abdominal computed tomography (CT) in 2 cases.

The CT scan is the main examination capable of making a correct diagnosis. However, as reported in the review of Pereira et al. [115], CT has a positive predictive value of only 60%. This can be explained by the simultaneous proximity of the two hepatic lobes to the gallbladder, simulating the contact and not the adhesion to the left lobe of the liver. Considering the position of the gallbladder, if it is in the normal site, its right margin generally appears free (**Figure 1A**). If the gallbladder is positioned on the left, its left margin may appear free (**Figure 1B**) or included in the left lobe with a space between the two hepatic lobes (**Figure 1C**), making diagnosis easy. If the gallbladder appears between the right and left hepatic lobes, the diagnosis may remain unknown (**Figure 1D**) mimicking hypertrophy of the left hepatic lobe as also reported by Banchini et al. [20] and Iskandar et al. [6].

However, the CT remains the main examination as it can provide the anatomical portal and arterial variations that, as we will see, frequently occur in association with this anomaly.

#### **3. Theories and embryology**

The embryological theories of LSG development are numerous and complex, but we can distinguish two main ones. The first theory concerns an alteration that only concerns the development of the gallbladder and a second one that concerns the development of the central portion of the liver and consequently the malpositioning of the gallbladder.

In the theory of gallbladder development proposed by Gross [116], there are two ways in which gallbladder can develop:

• The first modality suggests a normal growth of the gallbladder migrating from the right side of the liver to the left side and attaching to the left lobe. In this case, the cystic duct originates from the right side of the bile duct and moves anteriorly and to the left of the liver pedicle.

**Reference**

**131**

[2] [5] [8] [11] [14] [17] [20] [23] [26] [29] [32] [35] [38] [41] [44] [47] [50] [53] [56] [59] [62] [65]

Fujita

Fujita

Feldman

1 1 1

[66]

McGowan

[63]

Mazzamurro

[60]

Matsuoka

Ergun

Etter

1

[57]

Matsumura

Donthi

1 1

[54]

Matsumoto

[51]

Masood

Dhulkotia

1

[48]

Makni

Colovic

2

[45]

Maetani

Chung

Cirla

1

[42]

Lin

Chuang

Chrungoo

Bonomo

1 2 1 1

[39]

Leone

[36]

Lee

[33]

Kubo

[30]

Kinoshita

Bender

1

[27]

Banzo

1

[24]

Kelly Kim

Banchini

1

[21]

Kehr

Asonuma

4

[18]

Kawai

Aoki

1

[15]

Almodhaiberi

1

[12]

Jung Kanazumi

Abongwa

Alharthi

1

[9]

Jona

 **Author**

Abe

1 1

[6]

Iskandar

[3]

Ishii

1 1 1 1 2 1 1 1 4 2 1 10

1 1 1 1 1 1 1 1 1 1

[67]

Si-Youn

3

[64]

 Siebermair

[61]

Shirono

1

1

[58]

Shimizu

1

[55]

Shen

1

[52]

 Seiberman

[49]

Schiffino

1

1

[46]

Sakihara

1

[43]

Sadhu

1

[40]

Saafan

1

[37]

Rozsos

1

[34]

Rocca

1

[31]

Reddy

[28]

Rafailidis

1

1

[25]

Qureshi

1

[22]

Quah

1

*Left Side Gallbladder: Clinical and Anatomical Implication*

[19]

Pradeep

4

[16]

Ozeki

26

*DOI: http://dx.doi.org/10.5772/intechopen.92000*

[13]

Oshima

1

[10]

Ogino

[7]

Ogawa

[4]

Noritomi

1

1

1

 **Number of cases**

 **Reference**

**Author**

**Number of cases**

 **Reference**

 **Author**

 **Number of cases**


#### *Left Side Gallbladder: Clinical and Anatomical Implication DOI: http://dx.doi.org/10.5772/intechopen.92000*

**2. Estimation incidence and diagnosis**

[37] 1 out of 2536 (0.04%).

*Liver Pathology*

tomography (CT) in 2 cases.

[20] and Iskandar et al. [6].

**3. Theories and embryology**

ways in which gallbladder can develop:

anteriorly and to the left of the liver pedicle.

with this anomaly.

of the gallbladder.

**130**

describes 26 cases, with a total of 211 cases (**Table 1**).

The real estimation of this anomaly is very difficult because most of the published articles are case reports and only a few of them have high numbers of cases. The literature analysis revealed 114 articles concerning LSG: 89 authors describe 1 case only, 11 present 2 cases, 3 present 3 cases, 3 present 4 cases, 3 describe 6 cases, 1 describes 7 cases, 2 describe 9 cases, 1 describes 10 cases, and 1

The incidence is variable and remains always below 0.3%: Idu et al. [109] describe 5 cases of LSG on 1764 cases of cholecystectomy (0.3%), Nagai et al. [90] 3 cases out of 1621 (0.2%), Sadhu et al. [43] 1 out of 1258 (0.08%), and Rozsos et al.

at surgery. Also, Lee et al. [36], in his series of 10 cases operated on for cholecystic stones or acute cholecystitis symptoms, describes the discovery: intraoperative in 8 cases and as an incidental finding on abdominal computed

Naganuma et al. [87], in a series of 67.994 patients studied with ultrasound, found 18 cases of abnormal gallbladder position with an incidence of 0.026%. These included retrohepatic, supraphrenic, and floating gallbladder, and only nine cases of LSG, with an incidence of 0.013%. However, ultrasound is not the main exam to make the diagnosis. Pereira et al. [115] show that ultrasound has a positive predictive value of only 2.7% and that in 81.1% LSG is initially detected

The CT scan is the main examination capable of making a correct diagnosis. However, as reported in the review of Pereira et al. [115], CT has a positive predictive value of only 60%. This can be explained by the simultaneous

proximity of the two hepatic lobes to the gallbladder, simulating the contact and not the adhesion to the left lobe of the liver. Considering the position of the gallbladder, if it is in the normal site, its right margin generally appears free (**Figure 1A**). If the gallbladder is positioned on the left, its left margin may appear free (**Figure 1B**) or included in the left lobe with a space between the two hepatic lobes (**Figure 1C**), making diagnosis easy. If the gallbladder appears between the right and left hepatic lobes, the diagnosis may remain unknown (**Figure 1D**

mimicking hypertrophy of the left hepatic lobe as also reported by Banchini et al.

However, the CT remains the main examination as it can provide the anatomical portal and arterial variations that, as we will see, frequently occur in association

The embryological theories of LSG development are numerous and complex, but we can distinguish two main ones. The first theory concerns an alteration that only concerns the development of the gallbladder and a second one that concerns the development of the central portion of the liver and consequently the malpositioning

In the theory of gallbladder development proposed by Gross [116], there are two

• The first modality suggests a normal growth of the gallbladder migrating from the right side of the liver to the left side and attaching to the left lobe. In this case, the cystic duct originates from the right side of the bile duct and moves

)


**Table 1.** *Number of cases reported in the literature for each author.*

• The second modality hypothesizes the formation of the gallbladder directly on the left side of the bile duct with its positioning directly under the left hepatic lobe. In this case, the cystic duct originates in the left part of the bile duct.

*CT scan visualization of the gallbladder. (A) Normal right side gallbladder attached to the right lobe; (B) left side gallbladder attached to left lobe with empty space between gallbladder fundus and right lobe; (C) left side gallbladder with fundus surrounded by left lobe and empty space between right lobe and left lobe; (D) left side gallbladder interposed between right lobe and left lobe, mimicking hypertrophy of right lobe. RL: right lobe; LL:*

The literature defines as a true LSG when it is located on the right side of the round ligament, and the cystic duct is inserted on the left side of the bile duct. The presence of true LSG, described in this way, represents a remarkably rare event, constituting 4.3% of the cases of left side gallbladder [18], and most of the cases

The ways in which the cystic duct enters the biliary duct are numerous even in the absence of the left gallbladder, and as reported by Sarawagi et al. [117], the normal right conjunction is present in 51.1% of cases, while its medial (left) insertion can be presented in 16.1%. Pereira et al. [115], in his review, describe the insertion of the cystic duct on the right side 65.6%, on the left side of common hepatic duct 9.5%, left hepatic duct 9.5%, on the right hepatic duct 7.6%, and in a branch of the right hepatic duct 2.4%. Six patients had other minor biliary anoma-

The second theory about the development of the central portion of the liver was

To understand this complex theory, it is necessary to investigate some moments of fetal evolution, in which the persistence of a right umbilical vein and/or hypertrophy of the left portion of the liver seem to be associated. According to the embryological studies of Arey [118] when the embryo measures 6 mm, there are at

everyone having a branch that enters the liver. The two veins inside the liver have branches that join them together. When the embryo reaches the size of 7 mm, the right vein goes into atrophy leaving the left side predominant. It is assumed that, if the right side vein does not atrophy, there is a persistence of this umbilical vein either extrahepatic or intrahepatic. In this case, the opposite process to the previous

Although this theory seems to be the most accreditable, there are cases in the literature of persistence of the right umbilical vein with the gallbladder positioned

Lucidarme et al. [120] describe this variation in portal anatomy as a defect in the evolution of the central portion of the liver, in which the right and left parts join

one occurs, with atrophy of the left side and hypertrophy of the right side

normally, showing how this theory does not always prove to be real [42].

's veins, one on the right side and one on the left side,

's hypothesis) [119]. When this happens, we have the positioning of the

first described by Ozeki in 1987 [16] and later defined by Nagai in 1997 [90] as "right side round ligament." This theory is associated with numerous alterations in intrahepatic anatomy and appears to account for over 95% of cases in which a left

described are therefore a different alteration.

*Left Side Gallbladder: Clinical and Anatomical Implication*

*DOI: http://dx.doi.org/10.5772/intechopen.92000*

side gallbladder is present.

the same time two vitelline

gallbladder in the left portion of the liver.

(Matsumoto

**133**

**Figure 1.**

*left lobe; GB: gallbladder.*

lies, and one had a duplicate common bile duct (CBD).

#### *Liver Pathology*

*Left Side Gallbladder: Clinical and Anatomical Implication DOI: http://dx.doi.org/10.5772/intechopen.92000*

#### **Figure 1.**

*CT scan visualization of the gallbladder. (A) Normal right side gallbladder attached to the right lobe; (B) left side gallbladder attached to left lobe with empty space between gallbladder fundus and right lobe; (C) left side gallbladder with fundus surrounded by left lobe and empty space between right lobe and left lobe; (D) left side gallbladder interposed between right lobe and left lobe, mimicking hypertrophy of right lobe. RL: right lobe; LL: left lobe; GB: gallbladder.*

• The second modality hypothesizes the formation of the gallbladder directly on the left side of the bile duct with its positioning directly under the left hepatic lobe. In this case, the cystic duct originates in the left part of the bile duct.

The literature defines as a true LSG when it is located on the right side of the round ligament, and the cystic duct is inserted on the left side of the bile duct. The presence of true LSG, described in this way, represents a remarkably rare event, constituting 4.3% of the cases of left side gallbladder [18], and most of the cases described are therefore a different alteration.

The ways in which the cystic duct enters the biliary duct are numerous even in the absence of the left gallbladder, and as reported by Sarawagi et al. [117], the normal right conjunction is present in 51.1% of cases, while its medial (left) insertion can be presented in 16.1%. Pereira et al. [115], in his review, describe the insertion of the cystic duct on the right side 65.6%, on the left side of common hepatic duct 9.5%, left hepatic duct 9.5%, on the right hepatic duct 7.6%, and in a branch of the right hepatic duct 2.4%. Six patients had other minor biliary anomalies, and one had a duplicate common bile duct (CBD).

The second theory about the development of the central portion of the liver was first described by Ozeki in 1987 [16] and later defined by Nagai in 1997 [90] as "right side round ligament." This theory is associated with numerous alterations in intrahepatic anatomy and appears to account for over 95% of cases in which a left side gallbladder is present.

To understand this complex theory, it is necessary to investigate some moments of fetal evolution, in which the persistence of a right umbilical vein and/or hypertrophy of the left portion of the liver seem to be associated. According to the embryological studies of Arey [118] when the embryo measures 6 mm, there are at the same time two vitelline's veins, one on the right side and one on the left side, everyone having a branch that enters the liver. The two veins inside the liver have branches that join them together. When the embryo reaches the size of 7 mm, the right vein goes into atrophy leaving the left side predominant. It is assumed that, if the right side vein does not atrophy, there is a persistence of this umbilical vein either extrahepatic or intrahepatic. In this case, the opposite process to the previous one occurs, with atrophy of the left side and hypertrophy of the right side (Matsumoto's hypothesis) [119]. When this happens, we have the positioning of the gallbladder in the left portion of the liver.

Although this theory seems to be the most accreditable, there are cases in the literature of persistence of the right umbilical vein with the gallbladder positioned normally, showing how this theory does not always prove to be real [42].

Lucidarme et al. [120] describe this variation in portal anatomy as a defect in the evolution of the central portion of the liver, in which the right and left parts join

**Reference**

**132**

[68] [71] [74] [77] [80] [83] [86] [89]

[1] [94] [97] [100] [103] [106] [109] [112] **Table 1.** *Number of cases reported in the literature for each author.*

Ikoma

1

[113]

Idu

6

[110]

Nguyena

Nishio

Hwang Iaccarino

1

[107]

Newcombe

3

[104]

Nemours

Huang

Hopper

Hsu

9 6

[101]

Nastos

[98]

Namikawa

Herrington

Hirohata Hochstetter

1 1

[95]

[92]

Nagendram

Nakakubo

1

[90]

Nagay

Hasbahceci

1 1

[87]

Naganuma

[84]

Moriyama

Gui

1

[81]

Gondra

1

[78]

Moo-Young

Moravik

Futamura

1

[75]

Funakoshi

1

[72]

Mizray Mohammed

 **Author** Fukuda

1

[69]

Mendoza-Calderon

2 1 6 1 1 2 9 3 1 1 1 2 1 1 1 1

[114]

Zoulamoglou

[111]

Zografos

1

1

[108]

Yu

2

[105]

 Yamazaki

[102]

Wu

2

1

[99]

Wong

[96]

 Watanabe

[93]

Velimezis

7

1

1

[91]

Uesaka

2

[88]

 Tomiyama

[85]

Takiguchi

[82]

Takemura

1

1

1

[79]

 Tachibana

[76]

Szanto

1

2

[73]

Surjan

[70]

Strong

1

*Liver Pathology*

1

 **Number of cases**

 **Reference**

**Author**

**Number of cases**

 **Reference**

 **Author**

 **Number of cases** together in a variable way, renaming this as "Fusion of hepatic plans." Considering these different descriptions, we can say that there is an anomaly in the mechanism of persistence or atrophy of the right umbilical vein and/or the liver surrounding it.

Based on these descriptions, we propose to combine the mechanism of atrophy of the central part of the liver with persistence of the right umbilical vein and the mechanism of fusion of the plans, trying to verify how these can give rise to different anatomical variations. In this way, we create a classification that can explain how this anomaly can occur.

As seen before, during fetal development, the right and left umbilical veins have a Y shape with one arm entering the liver and one passing laterally to it. At this stage, there is a set of vessels inside the liver that connect the two internal branches of the intrahepatic umbilical veins. This connection forms a venous conduit that we will call "intrahepatic right umbilical vein" (IRUV), which flows directly into the ligament of Arantius or enters the right umbilical vein at Rex's recess. The extrahepatic portion of the right umbilical vein can enter the liver in a variable position between segment 5 and segment 4b. Imagine looking at the liver from its lower face, corresponding to segments 5 and 4b, we can divide this area into four parts as shown in **Figure 2**: the superficial part, corresponding to the acute margin of the liver, in the portion of segment 5 (**Figure 2**: yellow segment 5), and the portion of segment 4b (**Figure 2**: blue segment 4b) and a deep part toward the hilum of the liver (**Figure 2**: red segment 5; green segment 4b).

The involution of the right umbilical vein may affect the surrounding hepatic parenchyma differently, depending on its extension and site, determining unusual alterations.

If atrophy affects the superficial parts (**Figure 2**: yellow and blue), the result is a volumetric reduction in the corresponding liver segments. If the atrophy affects the deep part toward the hilum (**Figure 2**: red and green), we can have alterations that cause variations of the portal vein and the biliary tract. Complete or partial atrophy can also explain in various ways incomplete forms of gallbladder malposition such as the medioposition described by Hsu et al. [97].

The different possibilities with which the right umbilical vein can evolve are four, and we describe them as follows (**Figure 3**):

Type A: complete atrophy of the right umbilical vein and normal left umbilical vein.

Type B: atrophy of the right external umbilical vein and persistence of the IRUV.

Types C and D represent the cases in which a persistence of the right umbilical vein occurs instead of the normal left umbilical vein, classifying this as "true right

*Combination of the evolution process of right and left umbilical veins with atrophy mechanism of segment 5 and 4 (in red: right umbilical vein; in orange: intrahepatic umbilical vein; in yellow: left umbilical vein; in light blue: portal vein and its branches; and in blue: area of hypotrophy). A1-B1-C1-D1 corresponding to atrophy of segment 5 area; A2-B2-C2-D2 absence of liver atrophy; A3-B3-C3-D3 corresponding to atrophy of segment 4*

*Schematic evolution of right and left umbilical veins with different evolution processes. (Type A) Normal evolution with the persistence of the left umbilical vein. (Type B) Persistence of the left umbilical vein and intrahepatic umbilical vein. (Type C) Persistence of the right umbilical vein and persistence of the intrahepatic umbilical vein with atrophy of left umbilical vein. (Type D) Persistence of the right umbilical vein only (in red:*

*right umbilical vein; in orange: intrahepatic umbilical vein; in yellow: left umbilical vein).*

*Left Side Gallbladder: Clinical and Anatomical Implication*

*DOI: http://dx.doi.org/10.5772/intechopen.92000*

Combining these variations with how lower liver atrophy can occur, the follow-

A1: The right umbilical vein goes into complete atrophy and is accompanied by an excessive involution of segments 8-5-4b. In this case, the gallbladder will present

A3: The right umbilical vein goes into atrophy completely and is accompanied by

A2: The right umbilical vein goes into atrophy completely, and there is no

B1: The right external umbilical vein goes into atrophy, and the right intrahepatic umbilical vein persists. An involution in the segment 5 site is

parenchymal atrophy. This is the normal anatomy that is described.

involution of segment 4b with hypotrophy of the latter.

side round ligament."

to the left of the round ligament.

Type A:

**Figure 4.**

*area.*

**Figure 3.**

Type B:

**135**

ing classifications can be determined (**Figure 4**):

Type C: persistence of the IRUV and extrahepatic umbilical vein and atrophy of the left umbilical vein.

Type D: persistence of the right extrahepatic umbilical vein and atrophy of the left umbilical vein.

#### **Figure 2.**

*Liver with the central portion divided into four parts: the superficial part of segment 5 in yellow; the lower part close to the hilum in red; the superficial part of segment 4 in blue; and the lower part of segment 4 close to the hilum in green. (A) Superior view and (B) inferior view.*

*Left Side Gallbladder: Clinical and Anatomical Implication DOI: http://dx.doi.org/10.5772/intechopen.92000*

#### **Figure 3.**

together in a variable way, renaming this as "Fusion of hepatic plans." Considering these different descriptions, we can say that there is an anomaly in the mechanism of persistence or atrophy of the right umbilical vein and/or the liver surrounding it. Based on these descriptions, we propose to combine the mechanism of atrophy of the central part of the liver with persistence of the right umbilical vein and the mechanism of fusion of the plans, trying to verify how these can give rise to different anatomical variations. In this way, we create a classification that can

As seen before, during fetal development, the right and left umbilical veins have

The involution of the right umbilical vein may affect the surrounding hepatic parenchyma differently, depending on its extension and site, determining unusual

If atrophy affects the superficial parts (**Figure 2**: yellow and blue), the result is a volumetric reduction in the corresponding liver segments. If the atrophy affects the deep part toward the hilum (**Figure 2**: red and green), we can have alterations that cause variations of the portal vein and the biliary tract. Complete or partial atrophy can also explain in various ways incomplete forms of gallbladder malposition such

The different possibilities with which the right umbilical vein can evolve are

Type B: atrophy of the right external umbilical vein and persistence of the IRUV. Type C: persistence of the IRUV and extrahepatic umbilical vein and atrophy of

Type D: persistence of the right extrahepatic umbilical vein and atrophy of the

*Liver with the central portion divided into four parts: the superficial part of segment 5 in yellow; the lower part close to the hilum in red; the superficial part of segment 4 in blue; and the lower part of segment 4 close to the*

Type A: complete atrophy of the right umbilical vein and normal left

a Y shape with one arm entering the liver and one passing laterally to it. At this stage, there is a set of vessels inside the liver that connect the two internal branches of the intrahepatic umbilical veins. This connection forms a venous conduit that we will call "intrahepatic right umbilical vein" (IRUV), which flows directly into the ligament of Arantius or enters the right umbilical vein at Rex's recess. The extrahepatic portion of the right umbilical vein can enter the liver in a variable position between segment 5 and segment 4b. Imagine looking at the liver from its lower face, corresponding to segments 5 and 4b, we can divide this area into four parts as shown in **Figure 2**: the superficial part, corresponding to the acute margin of the liver, in the portion of segment 5 (**Figure 2**: yellow segment 5), and the portion of segment 4b (**Figure 2**: blue segment 4b) and a deep part toward the hilum of the

explain how this anomaly can occur.

liver (**Figure 2**: red segment 5; green segment 4b).

as the medioposition described by Hsu et al. [97].

four, and we describe them as follows (**Figure 3**):

*hilum in green. (A) Superior view and (B) inferior view.*

alterations.

*Liver Pathology*

umbilical vein.

the left umbilical vein.

left umbilical vein.

**Figure 2.**

**134**

*Schematic evolution of right and left umbilical veins with different evolution processes. (Type A) Normal evolution with the persistence of the left umbilical vein. (Type B) Persistence of the left umbilical vein and intrahepatic umbilical vein. (Type C) Persistence of the right umbilical vein and persistence of the intrahepatic umbilical vein with atrophy of left umbilical vein. (Type D) Persistence of the right umbilical vein only (in red: right umbilical vein; in orange: intrahepatic umbilical vein; in yellow: left umbilical vein).*

#### **Figure 4.**

*Combination of the evolution process of right and left umbilical veins with atrophy mechanism of segment 5 and 4 (in red: right umbilical vein; in orange: intrahepatic umbilical vein; in yellow: left umbilical vein; in light blue: portal vein and its branches; and in blue: area of hypotrophy). A1-B1-C1-D1 corresponding to atrophy of segment 5 area; A2-B2-C2-D2 absence of liver atrophy; A3-B3-C3-D3 corresponding to atrophy of segment 4 area.*

Types C and D represent the cases in which a persistence of the right umbilical vein occurs instead of the normal left umbilical vein, classifying this as "true right side round ligament."

Combining these variations with how lower liver atrophy can occur, the following classifications can be determined (**Figure 4**):

Type A:

A1: The right umbilical vein goes into complete atrophy and is accompanied by an excessive involution of segments 8-5-4b. In this case, the gallbladder will present to the left of the round ligament.

A2: The right umbilical vein goes into atrophy completely, and there is no parenchymal atrophy. This is the normal anatomy that is described.

A3: The right umbilical vein goes into atrophy completely and is accompanied by involution of segment 4b with hypotrophy of the latter.

Type B:

B1: The right external umbilical vein goes into atrophy, and the right intrahepatic umbilical vein persists. An involution in the segment 5 site is associated. In this case, there is the presence of left side gallbladder with the persistence of the right portal branch only for segments 6 and 7 and hypertrophy of the portal branch of segment 4.

B2: The right external umbilical vein goes into atrophy, and the right intrahepatic umbilical vein persists. There is no involution of the hepatic parenchyma with normal portal trifurcation.

B3: The right external umbilical vein goes into atrophy, and the right intrahepatic umbilical vein persists. It is associated with segment 4b hypotrophy. This determines the absence of the left portal branch and vascularization of segments 2 and 3 from the right portal branch through the persistent right umbilical vein portion.

Type C:

C1: The right extrahepatic and intrahepatic umbilical veins persist with atrophy of the left umbilical vein. An involution in the segment 5 site is associated. In this case, there is the presence of left side gallbladder with the persistence of the right portal branch only for segments 6 and 7 and the absence of segment 5 or 5 and 8. The vascularization of segments 2 and 3 and 4 occurs through the persistent right intrahepatic umbilical vein portion.

C2: The right extrahepatic and intrahepatic umbilical veins persist with atrophy of the left umbilical vein. No involution of the hepatic parenchyma occurs. The vascularization of the liver is arched from right to left giving, in sequence, the branch for segments 6 and 7, that of segments 5 and 8 and ending with the vascularization of segments 2 and 3 and 4 through the persistent intrahepatic right umbilical vein.

C3: The right extrahepatic and intrahepatic umbilical veins persist with atrophy of the left umbilical vein. An involution in the segment 4b site is associated. The vascularization of the liver is arched from right to left giving the branch for segments 6 and 7, the branch for segments 5 and 8 and ending with the vascularization of segments 2 and 3 through the persistent intrahepatic right umbilical vein.

Type D:

D1: The right extrahepatic umbilical vein persists with atrophy of the left umbilical vein. An involution in the segment 5 site is associated. In this case, there is the presence of left side gallbladder with the persistence of the right portal branch that vascularizes segments 6 and 7 and the absence of segment 5 or 5 and 8, and the left portal branch that vascularizes segments 2 and 3 and 4.

umbilical vein Type C1 (**Figure 6a**); Nagai et al. [90] describe a case with the absence of the right anterior portal branch, corresponding to Type B1, and the other

*Schematic representation published in the literature with comparison and reclassification with our*

*nomenclature. (a) Kawai description (12) corresponding to Type C; (b) Nagai description (3) corresponding to Types B1 and D1; (c) Maetani description (20) corresponding to Type B1-B1-B2; and (d) Banchini*

*Combination of the evolution process of right and left umbilical veins with atrophy mechanism of segments 5*

*and 4, associated rotation and fusion of the right and left liver.*

*Left Side Gallbladder: Clinical and Anatomical Implication*

*DOI: http://dx.doi.org/10.5772/intechopen.92000*

absence of the left portal branch that we call Type D1 (**Figure 6b**); Lin [42] describes tree cases of the absence of the right anterior portal branch,

portal branches, making this a further challenge.

**Figure 5.**

**Figure 6.**

**137**

*description (9) corresponding to Type A1.*

corresponding to Type B; Maetani et al. [45] also describe two cases that we classify as Type B1 and one case with the absence of the right anterior portal branch and a vascularization of segments 5 and 8 from the left portal one that we consider Type B2 (**Figure 6c**); Banchini et al. [20] describe the agenesis of segments 5 and 8 with the absence of the right anterior portal branch, Type A1 (**Figure 6d**). On the contrary, the classification we propose differs from Shindon's classification [121] in defining the true right side ligamentum teres. Comparing the three types of portal bifurcation listed by Shindon, we consider the "independent right lateral" one as Type A1, the "bifurcation" one as Type D, and "trifurcation" one as an intermediate of Types A1–A3 (**Figure 7**), concluding that only the "bifurcation type" could be considered as "true right side ligamentum teres." It is evident that these three variables of fusion, atrophy, and umbilical vein evolution can be combined in a considerably higher number of ways and may result in intermediate presentations. Likewise, using this principle, we can also hypothesize how the biliary tract variations occur. Even if we will not deal in this chapter, we underline that, as evidenced by Nishitai et al. [122], the Biliary tree could differ a lot from the corresponding

D2: The right extrahepatic umbilical vein persists with atrophy of the left umbilical vein. There is no involution of the hepatic parenchyma. In this case, the right portal branch that vascularizes segments 6–7 and 5–8 and the left portal branch that vascularizes segments 2 and 3 and 4 persist.

D3: The right extrahepatic umbilical vein persists with atrophy of the left umbilical vein. An involution is associated with segment 4b. In this case, the right portal branch that vascularizes segments 6–7 and 5–8 and the left portal branch that vascularizes segments 2 and 3 persist.

The principle of the fusion of the planes is necessary to be added at the classification performed by rotating or increasing the volume of one of the two hepatic lobes.

In this way, we can reposition the ligament tears in the position in which it is located once the complete fetal development has taken place. To clarify, we have modified the left liver portion by rotating it counterclockwise as shown in **Figure 5**.

We can see how this classification allows us to catalog the cases of literature described or represented with images, the portal modifications found: Kawai et al. [18] describe the absence of the left portal vein and a branch for the left liver originating from the right portal branch that we identify as an atrophy of left

*Left Side Gallbladder: Clinical and Anatomical Implication DOI: http://dx.doi.org/10.5772/intechopen.92000*

**Figure 5.**

associated. In this case, there is the presence of left side gallbladder with the persistence of the right portal branch only for segments 6 and 7 and hypertrophy of

B2: The right external umbilical vein goes into atrophy, and the right intrahepatic umbilical vein persists. There is no involution of the hepatic paren-

B3: The right external umbilical vein goes into atrophy, and the right intrahepatic umbilical vein persists. It is associated with segment 4b hypotrophy. This determines the absence of the left portal branch and vascularization of segments 2 and 3 from the right portal branch through the persistent right umbilical

C1: The right extrahepatic and intrahepatic umbilical veins persist with atrophy of the left umbilical vein. An involution in the segment 5 site is associated. In this case, there is the presence of left side gallbladder with the persistence of the right portal branch only for segments 6 and 7 and the absence of segment 5 or 5 and 8. The vascularization of segments 2 and 3 and 4 occurs through the persistent right

C2: The right extrahepatic and intrahepatic umbilical veins persist with atrophy of the left umbilical vein. No involution of the hepatic parenchyma occurs. The vascularization of the liver is arched from right to left giving, in sequence, the branch for segments 6 and 7, that of segments 5 and 8 and ending with the vascularization of segments 2 and 3 and 4 through the persistent intrahepatic right

C3: The right extrahepatic and intrahepatic umbilical veins persist with atrophy of the left umbilical vein. An involution in the segment 4b site is associated. The vascularization of the liver is arched from right to left giving the branch for segments 6 and 7, the branch for segments 5 and 8 and ending with the vascularization of segments 2 and 3 through the persistent intrahepatic right umbilical vein.

D1: The right extrahepatic umbilical vein persists with atrophy of the left umbilical vein. An involution in the segment 5 site is associated. In this case, there is the presence of left side gallbladder with the persistence of the right portal branch that vascularizes segments 6 and 7 and the absence of segment 5 or 5 and 8, and the

D2: The right extrahepatic umbilical vein persists with atrophy of the left umbilical vein. There is no involution of the hepatic parenchyma. In this case, the right portal branch that vascularizes segments 6–7 and 5–8 and the left portal

D3: The right extrahepatic umbilical vein persists with atrophy of the left umbilical vein. An involution is associated with segment 4b. In this case, the right portal branch that vascularizes segments 6–7 and 5–8 and the left portal branch that

The principle of the fusion of the planes is necessary to be added at the classification performed by rotating or increasing the volume of one of the two hepatic

In this way, we can reposition the ligament tears in the position in which it is located once the complete fetal development has taken place. To clarify, we have modified the left liver portion by rotating it counterclockwise as shown in **Figure 5**. We can see how this classification allows us to catalog the cases of literature described or represented with images, the portal modifications found: Kawai et al. [18] describe the absence of the left portal vein and a branch for the left liver originating from the right portal branch that we identify as an atrophy of left

left portal branch that vascularizes segments 2 and 3 and 4.

branch that vascularizes segments 2 and 3 and 4 persist.

vascularizes segments 2 and 3 persist.

the portal branch of segment 4.

vein portion. Type C:

*Liver Pathology*

umbilical vein.

Type D:

lobes.

**136**

chyma with normal portal trifurcation.

intrahepatic umbilical vein portion.

*Combination of the evolution process of right and left umbilical veins with atrophy mechanism of segments 5 and 4, associated rotation and fusion of the right and left liver.*

#### **Figure 6.**

*Schematic representation published in the literature with comparison and reclassification with our nomenclature. (a) Kawai description (12) corresponding to Type C; (b) Nagai description (3) corresponding to Types B1 and D1; (c) Maetani description (20) corresponding to Type B1-B1-B2; and (d) Banchini description (9) corresponding to Type A1.*

umbilical vein Type C1 (**Figure 6a**); Nagai et al. [90] describe a case with the absence of the right anterior portal branch, corresponding to Type B1, and the other absence of the left portal branch that we call Type D1 (**Figure 6b**); Lin [42] describes tree cases of the absence of the right anterior portal branch, corresponding to Type B; Maetani et al. [45] also describe two cases that we classify as Type B1 and one case with the absence of the right anterior portal branch and a vascularization of segments 5 and 8 from the left portal one that we consider Type B2 (**Figure 6c**); Banchini et al. [20] describe the agenesis of segments 5 and 8 with the absence of the right anterior portal branch, Type A1 (**Figure 6d**). On the contrary, the classification we propose differs from Shindon's classification [121] in defining the true right side ligamentum teres. Comparing the three types of portal bifurcation listed by Shindon, we consider the "independent right lateral" one as Type A1, the "bifurcation" one as Type D, and "trifurcation" one as an intermediate of Types A1–A3 (**Figure 7**), concluding that only the "bifurcation type" could be considered as "true right side ligamentum teres." It is evident that these three variables of fusion, atrophy, and umbilical vein evolution can be combined in a considerably higher number of ways and may result in intermediate presentations. Likewise, using this principle, we can also hypothesize how the biliary tract variations occur. Even if we will not deal in this chapter, we underline that, as evidenced by Nishitai et al. [122], the Biliary tree could differ a lot from the corresponding portal branches, making this a further challenge.

Anyway, the main risk factor seems to be the passage of the gallbladder anterior to the liver pedicle. This rotation moves Calot's triangle from horizontal and lateral to a vertical and anterior position, bringing the gallbladder closer to the biliary tract

In normal cholecystectomy, the opening of the Calot allows moving the gallbladder and cystic duct away from the biliary tract. This isolation is performed with a dissection directed from the superficial to the deep plane and is done by pulling the gallbladder laterally. The dissection finishes posterolaterally by finding an area free of tissue, corresponding to the posterior side on Calot's triangle. In the case of LSG, if we perform the dissection of the Calot using this method, we risk finding a posterior plane occupied by the biliary tract and liver peduncle instead of a free one

Taking into account this condition, it is necessary to look for a dissection modality that allows maintaining the distance from the biliary tract and the hepatic peduncle. We advocate performing laparoscopic cholecystectomy with fundus first technique [24] to achieve a proper distance from the hepatic pedicle. Once the body of the gallbladder is detached from the liver surface and Calot's triangle is joined, we recommend to follow the dissection close to the gallbladder border. The border dissection allows minimizing the removal of peripedicle fat tissue, avoiding unintended biliary duct discovery. In order to augment the distance from the pedicle and the biliary way, once the peritoneum of the Calot has been opened, it is advisable to pull the gallbladder on the lateral side to horizontalize the triangle itself. This traction can move the gallbladder on the right side of the hepatic pedicle, repurposing the normal anatomy. After this mobilization, it could be useful to apply the Strasberg criteria for the visualization of all structures [123], so that the cystic duct and cystic artery can be dissected and clipped distant from the biliary tract, after their recognition. In case of doubt, it is useful to perform an intraoperative cholangiography or visualize the biliary tract with the indocyanine green or finally

*Blue gallbladder; green cystic duct and biliary way; brown liver. (A) Normal gallbladder frontal view; (A1) normal gallbladder left lateral view; (B) left side gallbladder frontal view; and (B1) left side gallbladder left*

proceed with the conversion to have a direct view.

*Left Side Gallbladder: Clinical and Anatomical Implication*

*DOI: http://dx.doi.org/10.5772/intechopen.92000*

(**Figure 8**).

(**Figure 9**).

**Figure 8.**

*lateral view.*

**139**

#### **Figure 7.**

*Schematic representation of Shindon's classification (21) with comparison and reclassification with our nomenclature. (A) "Type A Shindon" corresponding to Type A1; (B) "Type B Shindon" corresponding to Type D; (C) "Type C Shindon" corresponding to intermediate Types A1–A3.*

Considering the numerous possibilities with which a left gallbladder can present, we recommend an accurate study of the entire hepatic anatomy, with the need to recognize the portal, arterial, and biliary changes, in all patients presenting this diagnosis in the preoperative setting.

#### **4. Clinical implication**

As pointed out in the previous paragraph, the presence of LSG is associated with a high number of variations both internal and external to the liver, regardless of the type of classification we want to use.

However, the presence of this anomaly does not seem to be associated with either a particular clinical manifestation or cancer, thus representing a simple anatomical variation presents in the population. The absence of symptoms makes the diagnosis of LSG an occasional event, consequent to its finding during investigations performed for other factors. Likewise, as in the normal population, gallstones follow the physiological mechanism of formation. However, gallbladder malpositioning does not seem to change the afferent pain pathways, and, as reviewed by Iskandar et al. [6] on 32 articles, the related symptoms are those of biliary colic or classic acute cholecystitis, with pain in the right upper quadrant or epigastric pain.

The diagnosis of gallbladder gallstones is mostly performed with ultrasound, but it has a very low diagnostic capacity in case of unknown LSG. Therefore, patients presenting with symptoms of biliary colic or acute gallbladder cholecystitis have a high probability to find this anomaly only during surgery. This condition exposes the patient and the surgeon to considerable risk. In the literature, cases of biliary lesions during cholecystectomy in LSG range from 4.4 [115] to 7.3% [5].

Laparoscopic cholecystectomy does not seem to be contraindicated, but some precautions are necessary to avoid risks of complications. Many authors advocate different techniques in trocar placement or in the patient's position, but this strategy could be applicable only in the case of preoperative diagnosis.

*Left Side Gallbladder: Clinical and Anatomical Implication DOI: http://dx.doi.org/10.5772/intechopen.92000*

Anyway, the main risk factor seems to be the passage of the gallbladder anterior to the liver pedicle. This rotation moves Calot's triangle from horizontal and lateral to a vertical and anterior position, bringing the gallbladder closer to the biliary tract (**Figure 8**).

In normal cholecystectomy, the opening of the Calot allows moving the gallbladder and cystic duct away from the biliary tract. This isolation is performed with a dissection directed from the superficial to the deep plane and is done by pulling the gallbladder laterally. The dissection finishes posterolaterally by finding an area free of tissue, corresponding to the posterior side on Calot's triangle. In the case of LSG, if we perform the dissection of the Calot using this method, we risk finding a posterior plane occupied by the biliary tract and liver peduncle instead of a free one (**Figure 9**).

Taking into account this condition, it is necessary to look for a dissection modality that allows maintaining the distance from the biliary tract and the hepatic peduncle. We advocate performing laparoscopic cholecystectomy with fundus first technique [24] to achieve a proper distance from the hepatic pedicle. Once the body of the gallbladder is detached from the liver surface and Calot's triangle is joined, we recommend to follow the dissection close to the gallbladder border. The border dissection allows minimizing the removal of peripedicle fat tissue, avoiding unintended biliary duct discovery. In order to augment the distance from the pedicle and the biliary way, once the peritoneum of the Calot has been opened, it is advisable to pull the gallbladder on the lateral side to horizontalize the triangle itself. This traction can move the gallbladder on the right side of the hepatic pedicle, repurposing the normal anatomy. After this mobilization, it could be useful to apply the Strasberg criteria for the visualization of all structures [123], so that the cystic duct and cystic artery can be dissected and clipped distant from the biliary tract, after their recognition. In case of doubt, it is useful to perform an intraoperative cholangiography or visualize the biliary tract with the indocyanine green or finally proceed with the conversion to have a direct view.

**Figure 8.**

Considering the numerous possibilities with which a left gallbladder can present, we recommend an accurate study of the entire hepatic anatomy, with the need to recognize the portal, arterial, and biliary changes, in all patients presenting this

*Schematic representation of Shindon's classification (21) with comparison and reclassification with our nomenclature. (A) "Type A Shindon" corresponding to Type A1; (B) "Type B Shindon" corresponding to Type*

As pointed out in the previous paragraph, the presence of LSG is associated with a high number of variations both internal and external to the liver, regardless of the

The diagnosis of gallbladder gallstones is mostly performed with ultrasound, but it has a very low diagnostic capacity in case of unknown LSG. Therefore, patients presenting with symptoms of biliary colic or acute gallbladder cholecystitis have a high probability to find this anomaly only during surgery. This condition exposes the patient and the surgeon to considerable risk. In the literature, cases of biliary

Laparoscopic cholecystectomy does not seem to be contraindicated, but some precautions are necessary to avoid risks of complications. Many authors advocate different techniques in trocar placement or in the patient's position, but this strat-

However, the presence of this anomaly does not seem to be associated with either a particular clinical manifestation or cancer, thus representing a simple anatomical variation presents in the population. The absence of symptoms makes the diagnosis of LSG an occasional event, consequent to its finding during investigations performed for other factors. Likewise, as in the normal population, gallstones

follow the physiological mechanism of formation. However, gallbladder malpositioning does not seem to change the afferent pain pathways, and, as reviewed by Iskandar et al. [6] on 32 articles, the related symptoms are those of biliary colic or classic acute cholecystitis, with pain in the right upper quadrant or

lesions during cholecystectomy in LSG range from 4.4 [115] to 7.3% [5].

egy could be applicable only in the case of preoperative diagnosis.

diagnosis in the preoperative setting.

*D; (C) "Type C Shindon" corresponding to intermediate Types A1–A3.*

type of classification we want to use.

**4. Clinical implication**

**Figure 7.**

*Liver Pathology*

epigastric pain.

**138**

*Blue gallbladder; green cystic duct and biliary way; brown liver. (A) Normal gallbladder frontal view; (A1) normal gallbladder left lateral view; (B) left side gallbladder frontal view; and (B1) left side gallbladder left lateral view.*

variations in the liver vascularization result in an increased risk during surgery. To prevent complications, we recommend performing a cholecystectomy with safety criteria, starting from the fundus and isolating Calot's triangle along the edge of the gallbladder. In the case of hepatic resection, an accurate study of the portal, arterial, and biliary branches should be done before surgery. This makes possible to plan an

A particular acknowledgment gives to "Associazione Carlo Malchiodi per le

Department of General Surgery, Guglielmo da Saliceto Hospital, Piacenza, Italy

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to: filippobanchini@virgilio.it

intervention tailored to the patient's anatomical condition.

*Left Side Gallbladder: Clinical and Anatomical Implication*

*DOI: http://dx.doi.org/10.5772/intechopen.92000*

Ricerche in Chirurgia ONLUS" for funding publication.

The author declares no conflict of interest.

**Acknowledgements**

**Conflict of interest**

**Author details**

**141**

Filippo Banchini\* and Patrizio Capelli

provided the original work is properly cited.

**Figure 9.**

*(A) Normal gallbladder frontal visual; (A1) normal gallbladder left lateral visual; (B) left side gallbladder frontal vision; (B1) left side gallbladder left lateral. Visual red arrow: direction of dissection in Calot's triangle.*

While accurate dissection and recognition of structures in cholecystectomy can prevent iatrogenic lesions, it is different in the case of liver resections. The anatomical variations that can occur are so high that a detailed study of portal, arterial, and biliary structures is mandatory. This necessity stems from the fact that the portal variations may not correspond to arterial or biliary anomalies, and therefore, all three of these structures must be considered separately. CT scan could be sufficient for portal and arterial study, and in particular, 3D CT could be particularly effective. On the opposite, the CT scan is not sufficient to demonstrate biliary variations, and for this reason, a magnetic resonance cholangiopancreatography is mandatory before elective major hepatectomy to ensure patient's safety [122].

Defining the types of resection is too complex, and therefore, each patient will require an on-demand treatment depending on the anomalies found. The main issue to keep in mind is that, in the case of LSG, liver supply can be sustained by only a single portal branch, as pointed out by Hsu et al. [97]. This eventuality is characterized by an arch shape of the portal vascularization visualized on CT scan, exposing the risk of extending resection to most of the liver itself.

The approach to LSG seems to have a significant clinical implication, augmenting the risk of complications in both liver resection and cholecystectomy. On one side, even if the probability to perform liver resection in LSG is very low, the risk is related to the major intrahepatic modification, on the other, considering cholecystectomy one of the most frequent interventions in surgery, the risk is related to the high probability to treat LSG as symptomatic gallbladder discovered intraoperatively.

#### **5. Conclusion**

Left side gallbladder is a rare and little known anomaly that is diagnosed, in most cases, during cholecystectomy for biliary colic or cholecystitis symptoms. The disposition of the gallbladder over the liver pedicle and the simultaneous presence of

*Left Side Gallbladder: Clinical and Anatomical Implication DOI: http://dx.doi.org/10.5772/intechopen.92000*

variations in the liver vascularization result in an increased risk during surgery. To prevent complications, we recommend performing a cholecystectomy with safety criteria, starting from the fundus and isolating Calot's triangle along the edge of the gallbladder. In the case of hepatic resection, an accurate study of the portal, arterial, and biliary branches should be done before surgery. This makes possible to plan an intervention tailored to the patient's anatomical condition.

#### **Acknowledgements**

A particular acknowledgment gives to "Associazione Carlo Malchiodi per le Ricerche in Chirurgia ONLUS" for funding publication.

#### **Conflict of interest**

While accurate dissection and recognition of structures in cholecystectomy can prevent iatrogenic lesions, it is different in the case of liver resections. The anatomical variations that can occur are so high that a detailed study of portal, arterial, and biliary structures is mandatory. This necessity stems from the fact that the portal variations may not correspond to arterial or biliary anomalies, and therefore, all three of these structures must be considered separately. CT scan could be sufficient for portal and arterial study, and in particular, 3D CT could be particularly effective. On the opposite, the CT scan is not sufficient to demonstrate biliary variations, and for this reason, a magnetic resonance cholangiopancreatography is mandatory

*(A) Normal gallbladder frontal visual; (A1) normal gallbladder left lateral visual; (B) left side gallbladder frontal vision; (B1) left side gallbladder left lateral. Visual red arrow: direction of dissection in Calot's triangle.*

Defining the types of resection is too complex, and therefore, each patient will require an on-demand treatment depending on the anomalies found. The main issue to keep in mind is that, in the case of LSG, liver supply can be sustained by only a single portal branch, as pointed out by Hsu et al. [97]. This eventuality is characterized by an arch shape of the portal vascularization visualized on CT scan, expos-

Left side gallbladder is a rare and little known anomaly that is diagnosed, in most cases, during cholecystectomy for biliary colic or cholecystitis symptoms. The disposition of the gallbladder over the liver pedicle and the simultaneous presence of

The approach to LSG seems to have a significant clinical implication, augmenting the risk of complications in both liver resection and cholecystectomy. On one side, even if the probability to perform liver resection in LSG is very low, the risk is related to the major intrahepatic modification, on the other, considering cholecystectomy one of the most frequent interventions in surgery, the risk is related to the high probability to treat LSG as symptomatic gallbladder discovered

before elective major hepatectomy to ensure patient's safety [122].

ing the risk of extending resection to most of the liver itself.

intraoperatively.

**Figure 9.**

*Liver Pathology*

**5. Conclusion**

**140**

The author declares no conflict of interest.

#### **Author details**

Filippo Banchini\* and Patrizio Capelli Department of General Surgery, Guglielmo da Saliceto Hospital, Piacenza, Italy

\*Address all correspondence to: filippobanchini@virgilio.it

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Hochstetter F. Anomaliem der pfortader und der nabelvene in verbindung mit defect oder Linkscage der gall-en-blase. Archiv für Mikroskopische Anatomie und Entwicklungsmechanik. 1886;**3**:369-384

[2] Abe K, Kajiyama N, Harimoto T, Gion K, Shirabe T. Nagaie, resection ofmetastatic liver cancer in a patient with a left-sided gallbladder andintrahepatic portal vein and bile duct anomalies: A case report. International Journal of Surgery Case Reports. 2012;**3**(5):147-150. Available from: https://www.sciencedirect.com/ science/article/pii/S2210261212000090? via%3Dihub

[3] Ishii H, Noguchi A, Onishi M, et al. True left-sided gallbladder withvariations of bile duct and cholecystic vein. World journal of gastroenterology. 2015;**21**(21): 6754-6758. DOI: 10.3748/wjg.v21. i21.6754

[4] Noritomi T, Watanabe K, Yamashita Y, Kitagawa S, Oshibuchi M, Shirakusa T. Left-sided gallbladder associated with congenital hypoplasia of the left lobe of the liver: A case report and review of literature. International Surgery. 2004;**89**:1-5

[5] Abongwa HK, De Simone B, Alberici L, Iaria M, Perrone G, Tarasconi A, et al. Implications of left-sided gallbladder in the emergency setting: Retrospective review and top tips for safe laparoscopiccholecystectomy. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 2017;**27**(4): 220-227. DOI: 10.1097/ SLE.0000000000000417

[6] Iskandar ME, Radzio A, Krikhely M, Leitman IM. Laparoscopic cholecystectomy for a left-sided gallbladder. World Journal of

Gastroenterology. 2013;**19**(35): 5925-5928

[7] Ogawa T, Ohwada S, Ikeya S, Shiozaki H, Aiba S, Morishita Y. Left sided gallbladder with anomalies of the intrhepatic portal vein and anomalous junction of the pancreatico-biliary ductal system: A case report. Hepatogastroenterology. 1995;**42**: 645-649

hepatectomy (in Japanese with English abstract). Geka. 2004;**66**:959-962

*DOI: http://dx.doi.org/10.5772/intechopen.92000*

*Left Side Gallbladder: Clinical and Anatomical Implication*

Surgery Case Reports. 2019;**60**: 249-252. DOI: 10.1016/j. ijscr.2019.06.034

[22] Quah GS, Ng IE, Punch G, Richardson AJ. True left-sided

1902;**49**:229

E334

[21] Kehr H. Hine seltene anomalie der gall en gange. Muench Med Weschr.

gallbladder: A rare anatomical anomaly and its associated surgical challenges. ANZ Journal of Surgery. 2019;**89**:E333-

[23] Banzo I, Carril JM, Arnal C. Left sided gallbladder. An incidental finding on hepatobiliary scintigraphy. Clinical Nuclear Medicine. 1990;**15**:358-359

[24] Kelly Michael D. Laparoscopic

19. DOI: 10.1186/1471-2482-9-19

[25] Qureshi Z. Awad, aberrant presentation of the gallbladder duringlaparoscopic cholecystectomy. JSLS. 2009;**13**(4):605-607. DOI: 10.4293/108680809X12589999538075

[26] Bender EA, Springhetti S, Shemisa K, Wittenauer J. Leftsided gallbladder (sinistroposition) with duplication of the common bile duct.

[27] Kim EJLJ, Song SY, Lee KG,

Park HK, Lee KS. Left-sided gallbladder with intra-hepatic portal vein anomalies: A single centre experience. Korean Journal of Hepato-Biliary-Pancreatic

[28] Rafailidis S, Varelas N, Kotsidis D. Rafailidis, two congenital anomalies in one: An ectopic gallbladder with phrygian cap deformity. Case

Reports in Radiology. 2014;**2014**:246476

[29] Bonomo BR, Veenstra TM,

Komar HM. Richter,

JSLS. 2007;**11**:148-150

Surgery. 2010;**14**:241-247

cholecystectomy. BMC Surgery. 2009;**9**:

retrograde (fundus first)

[14] Aoki H, Tagaya N, Kubota K. Laparoscopic cholecystectomy with miniaturized instruments for a leftsided gallbladder: A case report (in Japanese with English abstract). Japan Society for Endoscopic Surgery. 2001;**6**:

[15] Kanazumi N, Fujiwara M,

Sugimoto H, Fujii T, Nomoto S, Inoue S, et al. Laparoscopic cholecystectomy for left-sided gallbladder: Report of two cases. Hepato-Gastroenterology. 2007;

[16] Ozeki Y, Onitsuka A, Hayashi M, Sasaki E. Left-sided gallbladder: Report of a case and study of 26 cases in Japan. Nippon Geka Gakkai Zasshi. 1987;**88**:

transplantation from donors with the left-sided gallbladder/portal vein anomaly. Transplantation. 1999;**68**:

[18] Kawai K, Miyata N, Yuasa E, Takeuchi Y, Goto H, Miyake H, et al. Kobayashi, true left-sidedgallbladder with a portal anomaly: Report of a case. Surgery Today. November 2012;**42**(11): 1130-1134. DOI: 10.1007/s00595-011-

[19] Pradeep VM, Ramachandran K, Sasidharan K. Anomalous position of the gallbladder: Ultrasonographic and scintigraphic demonstration in four cases. Journal of Clinical Ultrasound.

[20] Banchini F, Ekpo EF, Conti L, Capelli P. Left side gallbladder with agenesis of right anterior sector and absence of right hepatic duct. A case report. International Journal of

[17] Asonuma K, Shapiro AM, Inomata Y, Uryuhara K, Uemoto S, Tanaka K. Living related liver

1610-1612. DOI: 10.1097/ 00007890-199911270-00031

261-265

**54**:674-676

1644-1650

0093-5

**143**

1992;**20**:593-597

[8] Alharthi S, Bernon M, Krige JE. Beware the left-sided gallbladder. South African Journal of Surgery. 2012;**50**: 88-89

[9] Jona G, Szaho L, Tasnadi L. A case of left sided gallbladder. Magyar Radiologia. 1961;**13**:115

[10] Ogino T, Ohwada S, Morishima I, Takahashi H, Ogawa T, Takei H, et al. Left-sided gallbladder resected by laparoscopic cholecystectomy (in Japanese with English abstract). Journal of Japan Surgical Association. 1996;**57**: 1203-1205

[11] Almodhaiberi H, Hwang S, Cho YJ, Kwon Y, Jung BH, Kim MH. Customized left-sided hepatectomy and bile duct resection for perihilar cholangiocarcinoma in a patient with left-sided gallbladder and multiple combined anomalies. Korean Journal of Hepato-Biliary-Pancreatic Surgery. 2015;**19**:30-34

[12] Jung HS, Huh K, Shin YH, et al. Left-sided gallbladder: A complicated percutaneous cholecystostomy and subsequent hepatic embolisation. The British Journal of Radiology. 2009;**82**: e141-e144

[13] Oshima I. A case of a left-sided gallbladder with right-sided round ligament which was performed partial *Left Side Gallbladder: Clinical and Anatomical Implication DOI: http://dx.doi.org/10.5772/intechopen.92000*

hepatectomy (in Japanese with English abstract). Geka. 2004;**66**:959-962

**References**

*Liver Pathology*

via%3Dihub

i21.6754

[1] Hochstetter F. Anomaliem der pfortader und der nabelvene in verbindung mit defect oder Linkscage

Entwicklungsmechanik. 1886;**3**:369-384

Gastroenterology. 2013;**19**(35):

[7] Ogawa T, Ohwada S, Ikeya S, Shiozaki H, Aiba S, Morishita Y. Left sided gallbladder with anomalies of the intrhepatic portal vein and anomalous junction of the pancreatico-biliary ductal system: A case report. Hepatogastroenterology. 1995;**42**:

[8] Alharthi S, Bernon M, Krige JE. Beware the left-sided gallbladder. South African Journal of Surgery. 2012;**50**:

[9] Jona G, Szaho L, Tasnadi L. A case of

[10] Ogino T, Ohwada S, Morishima I, Takahashi H, Ogawa T, Takei H, et al. Left-sided gallbladder resected by laparoscopic cholecystectomy (in Japanese with English abstract). Journal of Japan Surgical Association. 1996;**57**:

[11] Almodhaiberi H, Hwang S, Cho YJ,

Customized left-sided hepatectomy and

Kwon Y, Jung BH, Kim MH.

bile duct resection for perihilar cholangiocarcinoma in a patient with left-sided gallbladder and multiple combined anomalies. Korean Journal of Hepato-Biliary-Pancreatic Surgery.

[12] Jung HS, Huh K, Shin YH, et al. Left-sided gallbladder: A complicated percutaneous cholecystostomy and subsequent hepatic embolisation. The British Journal of Radiology. 2009;**82**:

[13] Oshima I. A case of a left-sided gallbladder with right-sided round ligament which was performed partial

left sided gallbladder. Magyar Radiologia. 1961;**13**:115

5925-5928

645-649

88-89

1203-1205

2015;**19**:30-34

e141-e144

[2] Abe K, Kajiyama N, Harimoto T, Gion K, Shirabe T. Nagaie, resection ofmetastatic liver cancer in a patient

andintrahepatic portal vein and bile duct anomalies: A case report. International Journal of Surgery Case Reports. 2012;**3**(5):147-150. Available from: https://www.sciencedirect.com/ science/article/pii/S2210261212000090?

[3] Ishii H, Noguchi A, Onishi M, et al.

Yamashita Y, Kitagawa S, Oshibuchi M, Shirakusa T. Left-sided gallbladder associated with congenital hypoplasia of the left lobe of the liver: A case report and review of literature. International

[6] Iskandar ME, Radzio A, Krikhely M,

der gall-en-blase. Archiv für Mikroskopische Anatomie und

with a left-sided gallbladder

True left-sided gallbladder withvariations of bile duct and cholecystic vein. World journal of gastroenterology. 2015;**21**(21): 6754-6758. DOI: 10.3748/wjg.v21.

[4] Noritomi T, Watanabe K,

[5] Abongwa HK, De Simone B, Alberici L, Iaria M, Perrone G, Tarasconi A, et al. Implications of left-sided gallbladder in the emergency setting: Retrospective review and top tips for safe laparoscopiccholecystectomy. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 2017;**27**(4):

Surgery. 2004;**89**:1-5

220-227. DOI: 10.1097/ SLE.0000000000000417

Leitman IM. Laparoscopic cholecystectomy for a left-sided gallbladder. World Journal of

**142**

[14] Aoki H, Tagaya N, Kubota K. Laparoscopic cholecystectomy with miniaturized instruments for a leftsided gallbladder: A case report (in Japanese with English abstract). Japan Society for Endoscopic Surgery. 2001;**6**: 261-265

[15] Kanazumi N, Fujiwara M, Sugimoto H, Fujii T, Nomoto S, Inoue S, et al. Laparoscopic cholecystectomy for left-sided gallbladder: Report of two cases. Hepato-Gastroenterology. 2007; **54**:674-676

[16] Ozeki Y, Onitsuka A, Hayashi M, Sasaki E. Left-sided gallbladder: Report of a case and study of 26 cases in Japan. Nippon Geka Gakkai Zasshi. 1987;**88**: 1644-1650

[17] Asonuma K, Shapiro AM, Inomata Y, Uryuhara K, Uemoto S, Tanaka K. Living related liver transplantation from donors with the left-sided gallbladder/portal vein anomaly. Transplantation. 1999;**68**: 1610-1612. DOI: 10.1097/ 00007890-199911270-00031

[18] Kawai K, Miyata N, Yuasa E, Takeuchi Y, Goto H, Miyake H, et al. Kobayashi, true left-sidedgallbladder with a portal anomaly: Report of a case. Surgery Today. November 2012;**42**(11): 1130-1134. DOI: 10.1007/s00595-011- 0093-5

[19] Pradeep VM, Ramachandran K, Sasidharan K. Anomalous position of the gallbladder: Ultrasonographic and scintigraphic demonstration in four cases. Journal of Clinical Ultrasound. 1992;**20**:593-597

[20] Banchini F, Ekpo EF, Conti L, Capelli P. Left side gallbladder with agenesis of right anterior sector and absence of right hepatic duct. A case report. International Journal of

Surgery Case Reports. 2019;**60**: 249-252. DOI: 10.1016/j. ijscr.2019.06.034

[21] Kehr H. Hine seltene anomalie der gall en gange. Muench Med Weschr. 1902;**49**:229

[22] Quah GS, Ng IE, Punch G, Richardson AJ. True left-sided gallbladder: A rare anatomical anomaly and its associated surgical challenges. ANZ Journal of Surgery. 2019;**89**:E333- E334

[23] Banzo I, Carril JM, Arnal C. Left sided gallbladder. An incidental finding on hepatobiliary scintigraphy. Clinical Nuclear Medicine. 1990;**15**:358-359

[24] Kelly Michael D. Laparoscopic retrograde (fundus first) cholecystectomy. BMC Surgery. 2009;**9**: 19. DOI: 10.1186/1471-2482-9-19

[25] Qureshi Z. Awad, aberrant presentation of the gallbladder duringlaparoscopic cholecystectomy. JSLS. 2009;**13**(4):605-607. DOI: 10.4293/108680809X12589999538075

[26] Bender EA, Springhetti S, Shemisa K, Wittenauer J. Leftsided gallbladder (sinistroposition) with duplication of the common bile duct. JSLS. 2007;**11**:148-150

[27] Kim EJLJ, Song SY, Lee KG, Park HK, Lee KS. Left-sided gallbladder with intra-hepatic portal vein anomalies: A single centre experience. Korean Journal of Hepato-Biliary-Pancreatic Surgery. 2010;**14**:241-247

[28] Rafailidis S, Varelas N, Kotsidis D. Rafailidis, two congenital anomalies in one: An ectopic gallbladder with phrygian cap deformity. Case Reports in Radiology. 2014;**2014**:246476

[29] Bonomo BR, Veenstra TM, Komar HM. Richter,

single-incisioncholecystectomy for leftsided gallbladder. JSLS. 2014;**18**(2): 338-341. DOI: 10.4293/108680813X13 693422518632

[30] Kinoshita H, Sahai K, Kubo S, Ohno K. Two cases of leftsided eallbladder associated with cholelithiasis: Review of the literature in Japan. Osaka City Medical Journal. 1964; **88**:494-497

[31] Reddy PK, Subramanian RV, Yuvaraja S. Laparoscopic cholecystectomy for left-sided gallbladder (sinistroposition). JSLS. 2005;**9**:356-357

[32] Chrungoo SL, Kachroo AK, Sharma AB, Khan AS. Nadim, left-sided gallbladder: Report of two cases. Journal of Minimal Access Surgery. 2007;**3**(3):108-110. DOI: 10.4103/ 0972-9941.37194

[33] Kubo S, Lee S, Yamamoto T, Edagawa A, Kinoshita H. Leftsided gallbladder associated with anomalous branching of the portal vein detected by sonography. Osaka City Medical Journal. 2000;**46**:95-98

[34] Rocca JP, Rodriguez-Davalos MI, Burke-Davis M, Marvin MR, Sheiner PA, Facciuto ME. Living-donor hepatectomy in right-sided roundligament liver: Importance of mapping the anatomy to the left medial segment. Journal of Hepato-Biliary-Pancreatic Surgery. 2006;**13**:454-457

[35] Chuang VP. The aberrant gallbladder: Angiographic and radioisotopic considerations. American Journal of Roentgenology. 1976;**127**: 417-421

[36] Lee DK, Park YH, Kim JS. Clinical significance and characteristics of leftsided gallbladder: Case series study of 10 patients. Annals of Surgical Treatment and Research. 2019;**97**(6): 302-308

[37] Rozsos I, Ferenczy J, Vincze K, Rainer S. Left sided gallbladder [in Hungarian]. Magyar Sebészet. 2002; **55**(5):329-330

right and malposition of the gallbladder.

*DOI: http://dx.doi.org/10.5772/intechopen.92000*

*Left Side Gallbladder: Clinical and Anatomical Implication*

cholecystectomy for acute cholecystitis associated with the left sided gallbladder and an aberrant hepatic duct. Japanese Journal of Gastroenterological Surgery.

[55] Shen BY. Sinistroposition of the gallbladder and common bile duct. Hepatobiliary & Pancreatic Diseases International. 2005;**4**:313-315

[56] Etter LE. Left sided gallbladder: Necessity for film of the entire abdomen incholecystography. American Journal of Roentgenology.

[57] Matsumura N, Tokumura H, Yasumoto A, Sasaki H, Yamasaki M,

cholecystocholedocholithiasis with a left-sided gallbladder: Report of a case. Surgery Today. 2009;**39**:252-255. DOI:

[58] Shimizu T, Hayashi M, Inoue Y, Komeda K, Asakuma M, Hirokawa F, et al. Living-donor liver transplantation from donor with a left-sided gallbladder

Transplantation. 2012;**94**:e60-e61

cholecystectomy of an ectopic

1988;**13**:256-258

Hospital. 2007;**27**:22-25

1477 [in Japanese]

[59] Feldman L, Venta L. Percutaneous

gallbladder. Gastrointestinal Radiology.

[60] Matsuoka N, Morimoto T, Yasui Y, Kita S, Yanai H, Matsuo K, et al. A case of a left-sided gallbladder (in Japanese with English abstract). J Kyoto City

[61] Shirono K, Kounosu H, Kubo H, et al. Case of left-sided gallbladder accompanying the anomalous

intrahepatic portal and hepatic venous

branching. Japanese Journal of Gastroenterological Surgery. 1990;**23**:

Musya H, et al. Laparoscopic cholecystectomy and common bile duct exploration for

10.1007/s00595-008-3837-0

with portal vein anomaly.

2008;**41**:1704-1709

1953;**70**:987

[46] Sakihara H, Yokota R, Yamaga S, Nagabuchi E, Kuribayashi H. A case of laparoscopic cholecystectomy for a left-

[47] Dhulkotia A, Kumar S, Kabra V, Shukla HS. Aberrant gallbladder situated beneath the left lobe of liver. HPB (Oxford). 2002;**4**:39-42. DOI: 10.1080/136518202753598726

[48] Makni A, Magherbi H, Ksantini R,

Rebai W, Safta ZB. Left-sided gallbladder: An incidental finding on laparoscopic cholecystectomy. Asian Journal of Surgery. 2012;**35**:93-95. DOI:

10.1016/j.asjsur.2012.04.011

[49] Schiffino L, Mouro J, Levard H, Dubois F. A case of a left-sided gallbladder treated surgically via laparoscopy. Annali Italiani di Chirurgia. 1993;**64**:229-231

[50] Donthi R, Thomas DJ, Sanders D, Schmidt SP. Report of laparoscopic cholecystectomy in two patients with left-sided gallbladders. JSLS. 2001;**5**:53-56

Chaudhary IA, Taimur. Laparoscopic cholecystectomyfor left sided gall bladder: An unusual case. Journal of Ayub Medical College, Abbottabad.

[52] Seiberman J et al. Left sided gallbladder. A rare anatomic variant.

[53] Ergun R. Sinistrac position of the gallbladder. Turk Tip Cem Mec. 1960;

[54] Matsumoto N, Hasegawa H, Shiroko T, Komatsu S, Kurumiya Y,

et al. A case of laparoscopic

Chirnag. 1986;**57**:653-654

[51] Masood R, Samiullah,

2009;**21**(1):162-163

**52**:344

**145**

Radiology. 1998;**207**:723-728

sided gallbladder, diagnosed intraoperatively (in Japanese with English abstract). Japan Society for Endoscopic Surgery. 2008;**13**:625-630

[38] Chung CC, Leung KL, Lau WY, Li AK. Ectopic gallbladder revisited, laparoscopically: A case report. Canadian Journal of Surgery. 1997;**40**: 464-466

[39] Leone V, Consolea BN. Management of incidental left-side gallbladder in laparoscopiccholecystectomy. Journal of Current Surgery. 2013;**3**(1):41-43

[40] Saafan T, Hu JY, Mahfouz AE, Abdelaal A. True left-sided gallbladder: A casereport and comparison with the literature for the different techniques oflaparoscopic cholecystectomy for such anomalies. International Journal of Surgery Case Reports. 2018;**42**:280-286. DOI: 10.1016/j.ijscr.2017.12.029

[41] Cirla A, De Vecchi A. Left sided ectopic gallbladder. Quaderni di Radiologia. 1965;**30**:749-758

[42] Lin HY. Is right-sided ligamentum teres hepatis always accompanied by left-sided gallbladder? Case reports and literature review. Insights into Imaging. 2018;**9**:955-960. DOI: 10.1007/s13244- 018-0671-9

[43] Sadhu S, Jahangir TA, Roy MK. Left-sided gallbladder discovered during laparoscopic cholecystectomy in a patient with dextrocardia. Indian Journal of Surgery. 2012;**74**:186-188. DOI: 10.1007/s12262-011-0261-2

[44] Colovic R, Colovic N, Barisic G, Atkinson HD, Krivokapic Z. Left-sided gallbladder associated with congenital liver cyst. HPB (Oxford). 2006;**8**: 157-158. DOI: 10.1080/ 13651820410016642

[45] Maetani Y, Itoh K, Kojima N, et al. Portal vein anomaly associated with deviation of the ligamentum teres to the *Left Side Gallbladder: Clinical and Anatomical Implication DOI: http://dx.doi.org/10.5772/intechopen.92000*

right and malposition of the gallbladder. Radiology. 1998;**207**:723-728

single-incisioncholecystectomy for leftsided gallbladder. JSLS. 2014;**18**(2): 338-341. DOI: 10.4293/108680813X13

[37] Rozsos I, Ferenczy J, Vincze K, Rainer S. Left sided gallbladder [in Hungarian]. Magyar Sebészet. 2002;

[38] Chung CC, Leung KL, Lau WY, Li AK. Ectopic gallbladder revisited, laparoscopically: A case report. Canadian Journal of Surgery. 1997;**40**:

[39] Leone V, Consolea BN. Management of incidental left-side gallbladder in laparoscopiccholecystectomy. Journal of Current Surgery. 2013;**3**(1):41-43

[40] Saafan T, Hu JY, Mahfouz AE, Abdelaal A. True left-sided gallbladder: A casereport and comparison with the literature for the different techniques oflaparoscopic cholecystectomy for such anomalies. International Journal of Surgery Case Reports. 2018;**42**:280-286.

DOI: 10.1016/j.ijscr.2017.12.029

[41] Cirla A, De Vecchi A. Left sided ectopic gallbladder. Quaderni di Radiologia. 1965;**30**:749-758

[42] Lin HY. Is right-sided ligamentum teres hepatis always accompanied by left-sided gallbladder? Case reports and literature review. Insights into Imaging. 2018;**9**:955-960. DOI: 10.1007/s13244-

[43] Sadhu S, Jahangir TA, Roy MK. Left-sided gallbladder discovered during laparoscopic cholecystectomy in a patient with dextrocardia. Indian Journal of Surgery. 2012;**74**:186-188. DOI: 10.1007/s12262-011-0261-2

[44] Colovic R, Colovic N, Barisic G, Atkinson HD, Krivokapic Z. Left-sided gallbladder associated with congenital liver cyst. HPB (Oxford). 2006;**8**:

[45] Maetani Y, Itoh K, Kojima N, et al. Portal vein anomaly associated with deviation of the ligamentum teres to the

157-158. DOI: 10.1080/ 13651820410016642

**55**(5):329-330

464-466

018-0671-9

[30] Kinoshita H, Sahai K, Kubo S, Ohno K. Two cases of leftsided eallbladder associated with

[31] Reddy PK, Subramanian RV,

[32] Chrungoo SL, Kachroo AK,

[33] Kubo S, Lee S, Yamamoto T, Edagawa A, Kinoshita H. Leftsided gallbladder associated with anomalous branching of the portal vein detected by

sonography. Osaka City Medical

Burke-Davis M, Marvin MR,

Surgery. 2006;**13**:454-457

417-421

302-308

**144**

[35] Chuang VP. The aberrant gallbladder: Angiographic and

[34] Rocca JP, Rodriguez-Davalos MI,

Sheiner PA, Facciuto ME. Living-donor hepatectomy in right-sided roundligament liver: Importance of mapping the anatomy to the left medial segment. Journal of Hepato-Biliary-Pancreatic

radioisotopic considerations. American Journal of Roentgenology. 1976;**127**:

[36] Lee DK, Park YH, Kim JS. Clinical significance and characteristics of leftsided gallbladder: Case series study of

10 patients. Annals of Surgical Treatment and Research. 2019;**97**(6):

Journal. 2000;**46**:95-98

Sharma AB, Khan AS. Nadim, left-sided gallbladder: Report of two cases. Journal of Minimal Access Surgery. 2007;**3**(3):108-110. DOI: 10.4103/

Yuvaraja S. Laparoscopic cholecystectomy for left-sided gallbladder (sinistroposition). JSLS.

cholelithiasis: Review of the literature in Japan. Osaka City Medical Journal. 1964;

693422518632

*Liver Pathology*

**88**:494-497

2005;**9**:356-357

0972-9941.37194

[46] Sakihara H, Yokota R, Yamaga S, Nagabuchi E, Kuribayashi H. A case of laparoscopic cholecystectomy for a leftsided gallbladder, diagnosed intraoperatively (in Japanese with English abstract). Japan Society for Endoscopic Surgery. 2008;**13**:625-630

[47] Dhulkotia A, Kumar S, Kabra V, Shukla HS. Aberrant gallbladder situated beneath the left lobe of liver. HPB (Oxford). 2002;**4**:39-42. DOI: 10.1080/136518202753598726

[48] Makni A, Magherbi H, Ksantini R, Rebai W, Safta ZB. Left-sided gallbladder: An incidental finding on laparoscopic cholecystectomy. Asian Journal of Surgery. 2012;**35**:93-95. DOI: 10.1016/j.asjsur.2012.04.011

[49] Schiffino L, Mouro J, Levard H, Dubois F. A case of a left-sided gallbladder treated surgically via laparoscopy. Annali Italiani di Chirurgia. 1993;**64**:229-231

[50] Donthi R, Thomas DJ, Sanders D, Schmidt SP. Report of laparoscopic cholecystectomy in two patients with left-sided gallbladders. JSLS. 2001;**5**:53-56

[51] Masood R, Samiullah, Chaudhary IA, Taimur. Laparoscopic cholecystectomyfor left sided gall bladder: An unusual case. Journal of Ayub Medical College, Abbottabad. 2009;**21**(1):162-163

[52] Seiberman J et al. Left sided gallbladder. A rare anatomic variant. Chirnag. 1986;**57**:653-654

[53] Ergun R. Sinistrac position of the gallbladder. Turk Tip Cem Mec. 1960; **52**:344

[54] Matsumoto N, Hasegawa H, Shiroko T, Komatsu S, Kurumiya Y, et al. A case of laparoscopic

cholecystectomy for acute cholecystitis associated with the left sided gallbladder and an aberrant hepatic duct. Japanese Journal of Gastroenterological Surgery. 2008;**41**:1704-1709

[55] Shen BY. Sinistroposition of the gallbladder and common bile duct. Hepatobiliary & Pancreatic Diseases International. 2005;**4**:313-315

[56] Etter LE. Left sided gallbladder: Necessity for film of the entire abdomen incholecystography. American Journal of Roentgenology. 1953;**70**:987

[57] Matsumura N, Tokumura H, Yasumoto A, Sasaki H, Yamasaki M, Musya H, et al. Laparoscopic cholecystectomy and common bile duct exploration for cholecystocholedocholithiasis with a left-sided gallbladder: Report of a case. Surgery Today. 2009;**39**:252-255. DOI: 10.1007/s00595-008-3837-0

[58] Shimizu T, Hayashi M, Inoue Y, Komeda K, Asakuma M, Hirokawa F, et al. Living-donor liver transplantation from donor with a left-sided gallbladder with portal vein anomaly. Transplantation. 2012;**94**:e60-e61

[59] Feldman L, Venta L. Percutaneous cholecystectomy of an ectopic gallbladder. Gastrointestinal Radiology. 1988;**13**:256-258

[60] Matsuoka N, Morimoto T, Yasui Y, Kita S, Yanai H, Matsuo K, et al. A case of a left-sided gallbladder (in Japanese with English abstract). J Kyoto City Hospital. 2007;**27**:22-25

[61] Shirono K, Kounosu H, Kubo H, et al. Case of left-sided gallbladder accompanying the anomalous intrahepatic portal and hepatic venous branching. Japanese Journal of Gastroenterological Surgery. 1990;**23**: 1477 [in Japanese]

[62] Fujita N, Shirai Y, Kawaguchi H, Tsukada K, Hatakeyama H. Left-sided gallbladder on the basis of a right-sided round ligament. Hepato-Gastroenterology. 1998;**45**:1482-1484

[63] Mazzamurro G, Di Lella V, Di Segni R. Comments on a case of left sided gallbladder. Radiologia Medica (Torino). 1981;**67**:476-480

[64] Siebermair J. Die linksseitige gallenblase eine selteneanatomische variante. Der Chirurg. 1986;**57**:653-654

[65] Fujita T, Ajiki T, Matsumoto T, Okazaki T, Matsumoto I, Kuroda Y, et al. Laparoscopic cholecystectomy for a leftsided gallbladder (in Japanese with English abstract). Japan Society for Endoscopic Surgery. 2007;**12**:403-407

[66] McGowan JM, Nussbaum CC, Burroughs EW. Cholecystitis due to giardia lambdia in a left sided gallbladder. Annals of Surgery. 1948; **128**:1032-1037

[67] Si-Youn R, Poong-Man J. Left-sided gallbladder with rightsided ligamentum teres hepatis: Rare associated anomaly of exomphalos. Journal of Pediatric Surgery. 2008;**43**:1390-1395. DOI: 10.1016/j.jpedsurg.2008.03.033

[68] Fukuda Y, Fujio N, Ihara T, Tsukazaki T, Koyama I, Tsukazaki Y, et al. A case of laparoscopic cholecystectomy for the left-sided gallbladder (in Japanese with English abstract). Geka. 2006;**68**:343-346

[69] Mendoza-Calderon JWS, Davila-Arriaga AR. Gallbladder to the left side of the falciform ligament in absence of Situs Inversus "Sinistroposition"—Case series of 2 patients with this anomaly who underwent mini-laparoscopic cholecystectomy. International Journal of Surgery Case Reports. 2018;**50**:36-41

[70] Strong RW, Fawcett J, Hatzifotis M, Hodgkinson P, Lynch S, O'Rourke T, et al. Surgical implications of a left-sided gallbladder. American Journal of Surgery. 2013;**206**:59-63. DOI: 10.1016/j.amjsurg.2012.10.035

[79] Tachibana H, Tachibana R, Tachibana T. Two case reports of left sided gallbladder. Shindan to Chiryou.

*DOI: http://dx.doi.org/10.5772/intechopen.92000*

*Left Side Gallbladder: Clinical and Anatomical Implication*

Naganuma H, et al. Sonographic findings of anomalous position of the gallbladder. Abdominal Radiology.

treated with laparoscopic

English abstract). Japan

[89] Hirohata et al. Hirohata

s40792-019-0614-9

**225**(3):274-280

Surgery. 1995;**2**:425-430

10.1016/j.ijscr.2017.11.004

[93] Velimezis G, Vassos N, Kapogiannatos G, et al. Left-sided gallbladder in the era of laparoscopic cholecystectomy: A single-center experience. The American Surgeon.

2015;**81**:1249-1252

[88] Tomiyama M, Okamura K, Kondo S, Kato H. A case of a leftsided gallbladder

Society for Endoscopic Surgery. 2002;**7**:

laparoscopic cholecystectomy for acute cholecystitis in a patient with left-sided gallbladder: A case report. Surgical Case Reports. 2019;**5**:54. DOI: 10.1186/

[90] Nagai M, Keiichi K, Seiji K, et al. Are left-sided gallbladders really located on the left side? Annals of Surgery. 1997;

[91] Uesaka K, Yasui K, Morimoto T, et al. Left-sided gallbladder with intrahepatic portal venous anomalies. Journal of Hepato-Biliary-Pancreatic

[92] Nagendram S, Lynes K, Hamade A. A case report on a left sided gallbladder: A rare finding during cholecystectomy. International Journal of Surgery Case Reports. 2017;**14**(41):398-400. DOI:

[94] Hopper N, Ryder JM, Swarnkar K, Stephenson BM. Laparoscopic left hepatic lobe cholecystectomy. Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A. 2003;**13**:405e406

[95] Nakakubo Y, Tanaka K, Tamoto E, Okushiba S, Kawamura K, Kondo S. A case of a left-sided gallbladder treated

cholecystectomy (in Japanese with

1998;**23**:67-72

65-69

1978;**66**:135-140 (in Japanese)

[80] Gui D, Magalini S, Prete F, Sermoneta D. What's right when the gallbladder's left? A case report. Surgical

[81] Moravik J. Left sided gallbladder— Laparoscopic cholecystectomy. Surgical

Gastroenterological Surgery. 1994;**27**:

[83] Hasbahceci M, Erol C, Seker M, Basak F, Alimoglu O. Standard laparoscopic cholecystectomy for malposition of the gallbladder caused by right-sided ligamentum teres. Journal of Minimal Access Surgery. 2013;**9**:177-179

[84] Moriyama S, Mori T, Umegae S. Two cases of left sided gallbladder with intrahepatic portal vein anomaly. Japanese Journal of Gastroenterological

[85] Takiguchi S, Sekimoto M, Matsui S, Yano H, Tateishi H, Kinuta M, et al. A case of left-sided gallbladder combined with an anomalous intrahepatic portal vein, confirmed by laparoscopic cholecystectomy (in Japanese with English abstract). Japanese Journal of Gastroenterological Surgery. 1996;**29**:

[86] Herrington JL Jr. Gallbladder arising from the left hepatic lobe. American Journal of Surgery. 1966;**112**:106-109

[87] Naganuma S, Ishida H, Konno K,

Hamashima Y, Hoshino T,

Surgery. 1990;**23**:2813-2817

Endoscopy. 2002;**16**:1637

Endoscopy. 2015;**29**:S188

2243-2247

2294-2298

**147**

[82] Takemura S, Yamasaki O, KwanChoon L, Mori A, Ikeda K, Kinoshita H, et al. A case of left-sided gallbladder and anomalous branching of the intrahepatic portal vein in which a Biliary cystadenoma of the liver was resected (in Japanese with English abstract). Japanese Journal of

[71] Funakoshi T, Kamiyama T, Nakagawa T, Sato N, Matsushita M, Todo S, et al. Resection of echinococcosis of the liver with the left-sided gallbladder and anomalous intrahepatic portal vein system: A case report (in Japanese with English abstract). Rinsyogeka. 2004;**59**: 743-746

[72] Mizray L. A case of left gallbladder. El Día Médico. 1960;**31**:2364

[73] Surjan RDT, Pinheiro JLS, Pinheiro PHS, da Silva IBM, do Prado Silveira S, Frugis MO. True left-sided gallbladder concomitant to direct insertion of the cystic duct into the duodenum: An extremely rare anatomic variation. Relatos Casos Cir. 2019;**5**(4): e2364. DOI: 10.30928/2527-2039e-20192364

[74] Futamura N, Matsumoto M, Yasumura M, Tateyama K, Tarao M, Sakamoto K, et al. A case of left-sided gallbladder (in Japanese). Gekachiryo. 2004;**90**:361-363

[75] Mohammed AA, Arif SH. Midline gallbladder makes a challenge for surgeons during laparoscopiccholecystectomy; case series of 6 patients. Annals of Medicine and Surgery. 2019;**40**:14-17

[76] Szanto I, Voros A, Altorjai A, Kiss J. Gallbladder in the left side of the lower abdomen. Endoscopy. 1996;**28**:49

[77] Gondra MD, Urien ID, Pturrioz T. Vesicula Biliar a la izquierda. Prensa Médica Argentina. 1954;**41**:124

[78] Moo-Young T, Picus DD, Teefey S, Strasberg SM. Common bile duct injury following laparoscopic cholecystectomy in the setting of sinistroposition of the gallbladder and bilairy confluence: A case report. Journal of Gastrointestinal Surgery. 2009;**14**:166-170

*Left Side Gallbladder: Clinical and Anatomical Implication DOI: http://dx.doi.org/10.5772/intechopen.92000*

[79] Tachibana H, Tachibana R, Tachibana T. Two case reports of left sided gallbladder. Shindan to Chiryou. 1978;**66**:135-140 (in Japanese)

[62] Fujita N, Shirai Y, Kawaguchi H, Tsukada K, Hatakeyama H. Left-sided gallbladder on the basis of a right-sided gallbladder. American Journal of Surgery. 2013;**206**:59-63. DOI: 10.1016/j.amjsurg.2012.10.035

[71] Funakoshi T, Kamiyama T, Nakagawa T, Sato N, Matsushita M,

echinococcosis of the liver with the left-sided gallbladder and anomalous intrahepatic portal vein system: A case report (in Japanese with

English abstract). Rinsyogeka. 2004;**59**:

[72] Mizray L. A case of left gallbladder.

Pinheiro PHS, da Silva IBM, do Prado Silveira S, Frugis MO. True left-sided gallbladder concomitant to direct insertion of the cystic duct into the duodenum: An extremely rare anatomic variation. Relatos Casos Cir. 2019;**5**(4): e2364. DOI: 10.30928/2527-2039e-

El Día Médico. 1960;**31**:2364

[73] Surjan RDT, Pinheiro JLS,

[74] Futamura N, Matsumoto M, Yasumura M, Tateyama K, Tarao M, Sakamoto K, et al. A case of left-sided gallbladder (in Japanese). Gekachiryo.

[75] Mohammed AA, Arif SH. Midline gallbladder makes a challenge for surgeons during laparoscopiccholecystectomy; case series of 6 patients. Annals of Medicine

[76] Szanto I, Voros A, Altorjai A, Kiss J. Gallbladder in the left side of the lower abdomen. Endoscopy. 1996;**28**:49

[77] Gondra MD, Urien ID, Pturrioz T. Vesicula Biliar a la izquierda. Prensa Médica Argentina. 1954;**41**:124

[78] Moo-Young T, Picus DD, Teefey S, Strasberg SM. Common bile duct injury following laparoscopic cholecystectomy in the setting of sinistroposition of the gallbladder and bilairy confluence: A case report. Journal of Gastrointestinal

and Surgery. 2019;**40**:14-17

Surgery. 2009;**14**:166-170

Todo S, et al. Resection of

743-746

20192364

2004;**90**:361-363

Gastroenterology. 1998;**45**:1482-1484

[63] Mazzamurro G, Di Lella V, Di Segni R. Comments on a case of left sided gallbladder. Radiologia Medica

[64] Siebermair J. Die linksseitige gallenblase eine selteneanatomische variante. Der Chirurg. 1986;**57**:653-654

[65] Fujita T, Ajiki T, Matsumoto T, Okazaki T, Matsumoto I, Kuroda Y, et al. Laparoscopic cholecystectomy for a leftsided gallbladder (in Japanese with English abstract). Japan Society for Endoscopic Surgery. 2007;**12**:403-407

[66] McGowan JM, Nussbaum CC, Burroughs EW. Cholecystitis due to giardia lambdia in a left sided gallbladder. Annals of Surgery. 1948;

[67] Si-Youn R, Poong-Man J. Left-sided gallbladder with rightsided ligamentum teres hepatis: Rare associated anomaly of exomphalos. Journal of Pediatric Surgery. 2008;**43**:1390-1395. DOI: 10.1016/j.jpedsurg.2008.03.033

[68] Fukuda Y, Fujio N, Ihara T, Tsukazaki T, Koyama I, Tsukazaki Y,

[69] Mendoza-Calderon JWS, Davila-Arriaga AR. Gallbladder to the left side of the falciform ligament in absence of Situs Inversus "Sinistroposition"—Case series of 2 patients with this anomaly who underwent mini-laparoscopic cholecystectomy. International Journal of Surgery Case Reports. 2018;**50**:36-41

[70] Strong RW, Fawcett J, Hatzifotis M, Hodgkinson P, Lynch S, O'Rourke T, et al. Surgical implications of a left-sided

**146**

et al. A case of laparoscopic cholecystectomy for the left-sided gallbladder (in Japanese with English abstract). Geka. 2006;**68**:343-346

**128**:1032-1037

round ligament. Hepato-

*Liver Pathology*

(Torino). 1981;**67**:476-480

[80] Gui D, Magalini S, Prete F, Sermoneta D. What's right when the gallbladder's left? A case report. Surgical Endoscopy. 2002;**16**:1637

[81] Moravik J. Left sided gallbladder— Laparoscopic cholecystectomy. Surgical Endoscopy. 2015;**29**:S188

[82] Takemura S, Yamasaki O, KwanChoon L, Mori A, Ikeda K, Kinoshita H, et al. A case of left-sided gallbladder and anomalous branching of the intrahepatic portal vein in which a Biliary cystadenoma of the liver was resected (in Japanese with English abstract). Japanese Journal of Gastroenterological Surgery. 1994;**27**: 2243-2247

[83] Hasbahceci M, Erol C, Seker M, Basak F, Alimoglu O. Standard laparoscopic cholecystectomy for malposition of the gallbladder caused by right-sided ligamentum teres. Journal of Minimal Access Surgery. 2013;**9**:177-179

[84] Moriyama S, Mori T, Umegae S. Two cases of left sided gallbladder with intrahepatic portal vein anomaly. Japanese Journal of Gastroenterological Surgery. 1990;**23**:2813-2817

[85] Takiguchi S, Sekimoto M, Matsui S, Yano H, Tateishi H, Kinuta M, et al. A case of left-sided gallbladder combined with an anomalous intrahepatic portal vein, confirmed by laparoscopic cholecystectomy (in Japanese with English abstract). Japanese Journal of Gastroenterological Surgery. 1996;**29**: 2294-2298

[86] Herrington JL Jr. Gallbladder arising from the left hepatic lobe. American Journal of Surgery. 1966;**112**:106-109

[87] Naganuma S, Ishida H, Konno K, Hamashima Y, Hoshino T,

Naganuma H, et al. Sonographic findings of anomalous position of the gallbladder. Abdominal Radiology. 1998;**23**:67-72

[88] Tomiyama M, Okamura K, Kondo S, Kato H. A case of a leftsided gallbladder treated with laparoscopic cholecystectomy (in Japanese with English abstract). Japan Society for Endoscopic Surgery. 2002;**7**: 65-69

[89] Hirohata et al. Hirohata laparoscopic cholecystectomy for acute cholecystitis in a patient with left-sided gallbladder: A case report. Surgical Case Reports. 2019;**5**:54. DOI: 10.1186/ s40792-019-0614-9

[90] Nagai M, Keiichi K, Seiji K, et al. Are left-sided gallbladders really located on the left side? Annals of Surgery. 1997; **225**(3):274-280

[91] Uesaka K, Yasui K, Morimoto T, et al. Left-sided gallbladder with intrahepatic portal venous anomalies. Journal of Hepato-Biliary-Pancreatic Surgery. 1995;**2**:425-430

[92] Nagendram S, Lynes K, Hamade A. A case report on a left sided gallbladder: A rare finding during cholecystectomy. International Journal of Surgery Case Reports. 2017;**14**(41):398-400. DOI: 10.1016/j.ijscr.2017.11.004

[93] Velimezis G, Vassos N, Kapogiannatos G, et al. Left-sided gallbladder in the era of laparoscopic cholecystectomy: A single-center experience. The American Surgeon. 2015;**81**:1249-1252

[94] Hopper N, Ryder JM, Swarnkar K, Stephenson BM. Laparoscopic left hepatic lobe cholecystectomy. Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A. 2003;**13**:405e406

[95] Nakakubo Y, Tanaka K, Tamoto E, Okushiba S, Kawamura K, Kondo S. A case of a left-sided gallbladder treated

using a laparoscopic cholecystectomy (in Japanese with English abstract). Rinsyogeka. 2006;**61**:995-997

[96] Watanabe O, Tsuchiya Y, Makino H, Tsutsui M, Nashimoto A, Sano M, et al. A case of left-sided gallbladder confirmed by laparoscopic cholecystectomy (in Japanese). Shujutsu. 1994;**48**:2241-2243

[97] Hsu T-YC, Huang T-L, Sun C-K, Mconcejero A, Tsang LL-C, Cheng Y-F. Left-sided gallbladder: Its clinical significance and imaging presentations. World Journal of Gastroenterology. 2007;**13**(December):6404-6409

[98] Namikawa T, Tamura K, Morita M, et al. Laparoscopic cholecystectomy for a patient with left-sided gallbladder. Surgical Technology International. 2015; **26**:120-123

[99] Wong J, Rusby T. Ismail, left-sided gall bladder: A diagnostic and surgicalchallenge. ANZ Journal of Surgery. 2001;**71**:557-558. DOI: 10.1046/ j.1440-1622.2001.02195.x

[100] Huang T, Yamasaki Y, Yamasaki H, Fukui Y, Hatanaka N, Okuno S, et al. Six cases of laparoscopic cholecystectomy to leftsided gallbladder (in Japanese with English abstract). Journal of Japan Surgical Association. 2000;**61**:458-461

[101] Nastos C, Vezakis A, Papaconstantinou I, Theodosopoulos T, Koutoulidis V, Polymeneas G. Methods of safe laparoscopic cholecystectomy for left-sided (sinistroposition) gallbladder: A report of two cases and a review of safe techniques. International Journal of Surgery Case Reports. 2014;**5**:769-773

[102] Wu TC, Lee RC, Chiang JH, Chang CY. Reappraisal of left-sided gallbladderand its accompanying anomalies: A report of two cases and literature review. Acta Radiologica.

2005;**46**:233-236. DOI: 10.1080/ 02841850510012706

[103] Hwang S, Lee SG, Park KM, et al. Hepatectomy of living donors with a left-sided gallbladder and multiple combined anomalies for adult-toadult living donor liver transplantation. Liver Transplantation. 2004;**10**:141-146

gallbladder. JSLS. 2009;**13**(April–June):

*DOI: http://dx.doi.org/10.5772/intechopen.92000*

*Left Side Gallbladder: Clinical and Anatomical Implication*

Japanese Journal of Medical Ultrasonics.

Mehdi C, Laurent H, Grenier Philippe A. Fusion of the midplane with the left intersectional plane: A liver anatomical variation revisited with multidetectorrow CT. European Radiology. 2006;**16**: 1699-1708. DOI: 10.1007/s00330-006-

[121] Shindoh J, Akahane M, Satou S, Aoki T, Beck Y, Hasegawa K, et al. Vascular architecture in anomalous right-sided ligamentum teres: Threedimensional analyses in 35 patients.

[122] Nishitai R, Shindoh J, Yamaoka T, Akahane M, Kokudo N, Manaka D. Biliary architecture of livers exhibiting right-sided ligamentum teres: An indication for preoperative cholangiography prior to major hepatectomy. HPB. 2016;**18**:929-935. DOI: 10.1016/j.hpb.2016.08.002

[123] Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in

laparoscopic cholecystectomy. Journal of the American College of Surgeons. 2010;**211**(July). DOI: 10.1016/

j.jamcollsurg.2010.02.053

[120] Olivier L, Jacques T, Eric S,

1986;**13**:551-552

0245-y

HPB. 2012;**14**:32-41

[112] Ikoma A, Tamaka K, Hamada N. Left sided gallbladder with accessory liver accompanied by intra-hepatic cholangiocarcinoma. Journal of the Japanese Surgical Society. 1992;**93**:

[113] Nishio H, Hasegawa H, Ogiso S. A case of the left-sided gallbladder with gallstones treated with laparoscopic cholecystectomy. Tan to Sui. 1995;**16**:

[114] Zoulamoglou M, Flessas I, Zarokosta M, et al. Left-sided gallbladder(Sinistroposition) encountered during laparoscopic cholecystectomy: A rarecase report and review of the literature. International Journal of Surgery. 2017;**31**:65-67. DOI:

10.1016/j.ijscr.2017.01.011

10.1111/ans.15041

[115] Ryan P, Talbir S, John A, Sam B, Eslick Guy D, Cox Michael R. Left-sided gallbladder: A systematic review of a rare biliary anomaly. ANZ Journal of Surgery. 2019;**89**:1392-1397. DOI:

[116] Gross RE. Congenital anomalies of the gallbladder. A review of 148 cases, with report of a double gallbladder. Archives of Surgery. 1936;**32**:131-162

[117] Radha S, Shyam S, Gupta SK, Sameer R. Anatomical variations of cystic ducts in magnetic resonance cholangiopancreatography and clinical implications. Radiology Research and Practice. 2016. p. 6. Article ID 3021484.

[118] Arey LB. Developmental Anatomy; A Text Book and Laboratory Manual of Embryology. 7th ed. Philadelphia: WB

[119] Matsumoto H. A newer concept of

DOI: 10.1155/2016/3021484

Saunders Co; 1965

**149**

the segments of the liver.

434-436 [in Japanese]

273-275

697-701

[104] Nemours, Auguste, Barrag. Sur un cas de vesicule biliare flottante a gauche. Arch Mal Appar Dig. 1951;**40**:453

[105] Yamazaki M, Takahashi K. Left sided gallbladder. Rinsho Hoshasen. 1970;**15**:341-345

[106] Iaccarino AI, Done A. Su di un caso di cholecisti a sinistra G. Tal Chir. 1955; **11**:1073

[107] Newcombe JF, Henley FA. Leftsided gallbladder. A review of the literature and a report of a case associated with hepatic duct carcinoma. Archives of Surgery. 1964;**88**:494-497

[108] Yu T, Wu SD, Min L. Incidental left-sided gallbladder during laparoscopic cholecystectomy for cholelithiasis. The American Surgeon. 2012;**78**:492-493

[109] Idu M, Jakimowicz J, Iuppa A, Cuschieri A. Hepatobiliary anatomy in patients with transposition of the gallbladder: Implications for safe laparoscopic cholecystectomy. British Journal of Surgery. 1996;**83**:1442-1443

[110] Nguyen TH, Nguyen TS, Van Nguyen PD, Dang TN, Talarico EF Jr. Sinistroposition: A case report of true left-sided gallbladder in a Vietnamese patient. International Journal of Surgery Case Reports. 2018;**51**:82-85

[111] Zografos GC, Lagoudianakis EE, Grosomanidis D, Koronakis N, Tsekouras D, Chrysikos J, et al. Management of incidental left-sided

*Left Side Gallbladder: Clinical and Anatomical Implication DOI: http://dx.doi.org/10.5772/intechopen.92000*

gallbladder. JSLS. 2009;**13**(April–June): 273-275

using a laparoscopic cholecystectomy (in Japanese with English abstract). Rinsyogeka. 2006;**61**:995-997

2005;**46**:233-236. DOI: 10.1080/

[103] Hwang S, Lee SG, Park KM, et al. Hepatectomy of living donors with a left-sided gallbladder and multiple combined anomalies for adult-toadult living donor liver transplantation. Liver Transplantation. 2004;**10**:141-146

[104] Nemours, Auguste, Barrag. Sur un cas de vesicule biliare flottante a gauche. Arch Mal Appar Dig. 1951;**40**:453

[105] Yamazaki M, Takahashi K. Left sided gallbladder. Rinsho Hoshasen.

[106] Iaccarino AI, Done A. Su di un caso di cholecisti a sinistra G. Tal Chir. 1955;

[107] Newcombe JF, Henley FA. Leftsided gallbladder. A review of the literature and a report of a case

associated with hepatic duct carcinoma. Archives of Surgery. 1964;**88**:494-497

[108] Yu T, Wu SD, Min L. Incidental

[109] Idu M, Jakimowicz J, Iuppa A, Cuschieri A. Hepatobiliary anatomy in patients with transposition of the gallbladder: Implications for safe laparoscopic cholecystectomy. British Journal of Surgery. 1996;**83**:1442-1443

[110] Nguyen TH, Nguyen TS, Van Nguyen PD, Dang TN, Talarico EF Jr. Sinistroposition: A case report of true left-sided gallbladder in a Vietnamese patient. International Journal of Surgery

[111] Zografos GC, Lagoudianakis EE, Grosomanidis D, Koronakis N, Tsekouras D, Chrysikos J, et al. Management of incidental left-sided

Case Reports. 2018;**51**:82-85

left-sided gallbladder during laparoscopic cholecystectomy for cholelithiasis. The American Surgeon.

2012;**78**:492-493

02841850510012706

1970;**15**:341-345

**11**:1073

[97] Hsu T-YC, Huang T-L, Sun C-K, Mconcejero A, Tsang LL-C, Cheng Y-F. Left-sided gallbladder: Its clinical significance and imaging presentations. World Journal of Gastroenterology. 2007;**13**(December):6404-6409

[98] Namikawa T, Tamura K, Morita M, et al. Laparoscopic cholecystectomy for a patient with left-sided gallbladder. Surgical Technology International. 2015;

[99] Wong J, Rusby T. Ismail, left-sided

gall bladder: A diagnostic and surgicalchallenge. ANZ Journal of Surgery. 2001;**71**:557-558. DOI: 10.1046/

j.1440-1622.2001.02195.x

2000;**61**:458-461

**148**

[100] Huang T, Yamasaki Y, Yamasaki H, Fukui Y, Hatanaka N, Okuno S, et al. Six cases of laparoscopic cholecystectomy to leftsided gallbladder (in Japanese with English abstract). Journal of Japan Surgical Association.

[101] Nastos C, Vezakis A,

Papaconstantinou I, Theodosopoulos T, Koutoulidis V, Polymeneas G. Methods of safe laparoscopic cholecystectomy for left-sided (sinistroposition) gallbladder: A report of two cases and a review of safe techniques. International Journal of Surgery Case Reports. 2014;**5**:769-773

[102] Wu TC, Lee RC, Chiang JH, Chang CY. Reappraisal of left-sided gallbladderand its accompanying anomalies: A report of two cases and literature review. Acta Radiologica.

**26**:120-123

[96] Watanabe O, Tsuchiya Y, Makino H, Tsutsui M, Nashimoto A, Sano M, et al. A case of left-sided gallbladder confirmed by laparoscopic cholecystectomy (in Japanese). Shujutsu. 1994;**48**:2241-2243

*Liver Pathology*

[112] Ikoma A, Tamaka K, Hamada N. Left sided gallbladder with accessory liver accompanied by intra-hepatic cholangiocarcinoma. Journal of the Japanese Surgical Society. 1992;**93**: 434-436 [in Japanese]

[113] Nishio H, Hasegawa H, Ogiso S. A case of the left-sided gallbladder with gallstones treated with laparoscopic cholecystectomy. Tan to Sui. 1995;**16**: 697-701

[114] Zoulamoglou M, Flessas I, Zarokosta M, et al. Left-sided gallbladder(Sinistroposition) encountered during laparoscopic cholecystectomy: A rarecase report and review of the literature. International Journal of Surgery. 2017;**31**:65-67. DOI: 10.1016/j.ijscr.2017.01.011

[115] Ryan P, Talbir S, John A, Sam B, Eslick Guy D, Cox Michael R. Left-sided gallbladder: A systematic review of a rare biliary anomaly. ANZ Journal of Surgery. 2019;**89**:1392-1397. DOI: 10.1111/ans.15041

[116] Gross RE. Congenital anomalies of the gallbladder. A review of 148 cases, with report of a double gallbladder. Archives of Surgery. 1936;**32**:131-162

[117] Radha S, Shyam S, Gupta SK, Sameer R. Anatomical variations of cystic ducts in magnetic resonance cholangiopancreatography and clinical implications. Radiology Research and Practice. 2016. p. 6. Article ID 3021484. DOI: 10.1155/2016/3021484

[118] Arey LB. Developmental Anatomy; A Text Book and Laboratory Manual of Embryology. 7th ed. Philadelphia: WB Saunders Co; 1965

[119] Matsumoto H. A newer concept of the segments of the liver.

Japanese Journal of Medical Ultrasonics. 1986;**13**:551-552

[120] Olivier L, Jacques T, Eric S, Mehdi C, Laurent H, Grenier Philippe A. Fusion of the midplane with the left intersectional plane: A liver anatomical variation revisited with multidetectorrow CT. European Radiology. 2006;**16**: 1699-1708. DOI: 10.1007/s00330-006- 0245-y

[121] Shindoh J, Akahane M, Satou S, Aoki T, Beck Y, Hasegawa K, et al. Vascular architecture in anomalous right-sided ligamentum teres: Threedimensional analyses in 35 patients. HPB. 2012;**14**:32-41

[122] Nishitai R, Shindoh J, Yamaoka T, Akahane M, Kokudo N, Manaka D. Biliary architecture of livers exhibiting right-sided ligamentum teres: An indication for preoperative cholangiography prior to major hepatectomy. HPB. 2016;**18**:929-935. DOI: 10.1016/j.hpb.2016.08.002

[123] Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. Journal of the American College of Surgeons. 2010;**211**(July). DOI: 10.1016/ j.jamcollsurg.2010.02.053

**151**

**Chapter 8**

**Abstract**

Tumors

Stereotactic Image-Guidance

for Ablation of Malignant Liver

*Iwan Paolucci, Raluca-Maria Sandu, Pascale Tinguely,* 

*Corina Kim-Fuchs, Martin Maurer, Daniel Candinas,* 

**Keywords:** image-guidance, ablation, microwave/radiofrequency ablation,

the shorter hospital stay compared to patients undergoing surgery [1].

Thermal ablation of liver tumors is a minimally invasive locally destructive treatment alternative to surgical resection, which is the current gold standard for curative care. Not only is ablation considered for patients not amenable for surgical resection (<20%) but also increasingly for resectable tumors even with a curative intent [1–3]. Percutaneous ablation is generally performed under image-guidance based on CT, MRI, or ultrasound. Stereotactic image-guidance leads to a simple, fast, and accurate placement of the ablation needle into the liver tumor. Patients undergoing a percutaneous ablation benefit from an improved quality of life due to

irreversible electroporation, liver tumors

**1. Introduction**

Stereotactic percutaneous ablation is a rapidly advancing modality for treatment of tumors in soft solid organs such as the liver. Each year, there are about 850,000 cases of primary liver cancer worldwide. Although surgical resection still is the gold standard for most cases, only 20–30% of patients are candidates for it, due to the advanced stage of the disease. Surgery can also be a huge burden to the patient and his/her quality of life might be temporarily severely reduced due to long hospital stays, complications, and slow recovery. To overcome these disadvantages, thermoablation of tumors of up to 3 cm has become a more viable alternative especially in the last decade, offering a potentially equally effective but minimally invasive and tissue sparing treatment alternative. In conjunction with improved CT imaging, stereotactic image-guidance techniques and image fusion technology were introduced to increase safety, efficacy, and accuracy of this treatment. Stereotactic image-guidance leads to a simple, fast, and accurate placement of the ablation probe into the liver tumor, which is a prerequisite for a complete destruction of the tumor by ablation. More and more physicians, including surgeons, consider ablation a viable alternative to resection whenever feasible. Patients undergoing such a minimally invasive treatment benefit from a shorter hospital stays, reduced complication rates, and faster recovery.

*Stefan Weber and Anja Lachenmayer*

#### **Chapter 8**
