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An elderly lady presented to the ER with sudden severe RLQ abdominal pain. A CT scan was ordered because of concerns for acute appendicitis. Did she have appendicits? No she did not. That amorphous, dark glob you see is actually the patient's gallbladder, down below the level of her anterior superior iliac spine. We corrected her INR and took to surgery. Asleep and anesthetized on the table you could feel the firm mass down in the right lower quadrant. "You'll have to stick one of your ports in her upper thigh", my assistant quipped.
Upon insufflation we encountered a massive, gangrenous gallbladder just sort of floating around on the right side of her abdomen. Completely unfixed from the liver it seemed, as if someone had already been by to remove it but forgot to extract it at the end of the case. With a little manipulation I was able to detorse the rotten sac and flip it over the liver. It had twisted around the axis of the cystic artery. I placed a couple of clips on the the important structures, bagged it, and drew it out of her forever. 90% of her gallbladder was completely untethered to her liver bed.
Gallbladder volvulus is a pretty rare phenomenon. 300 or so cases have been described in the literature. You can read your little heart out here, here and here. Most patients are elderly thin females. The pathophysiology under girding the disease is a poorly fixated, completely peritonealized gallbladder. Most of the time, a large percentage of the back wall of the gallbladder is adherent to the liver. This seems to fixate the GB pretty well and prevent unwelcome contortionist maneuverings. as above. In the elderly, loss of fat and general atrophy of tissues may contribute. The lady felt much better afterwards. She went home in a couple days, albeit unhappy about the hospital food. The fry had been dry. Who doesn't know how to cook fish?
Upon insufflation we encountered a massive, gangrenous gallbladder just sort of floating around on the right side of her abdomen. Completely unfixed from the liver it seemed, as if someone had already been by to remove it but forgot to extract it at the end of the case. With a little manipulation I was able to detorse the rotten sac and flip it over the liver. It had twisted around the axis of the cystic artery. I placed a couple of clips on the the important structures, bagged it, and drew it out of her forever. 90% of her gallbladder was completely untethered to her liver bed.
Gallbladder volvulus is a pretty rare phenomenon. 300 or so cases have been described in the literature. You can read your little heart out here, here and here. Most patients are elderly thin females. The pathophysiology under girding the disease is a poorly fixated, completely peritonealized gallbladder. Most of the time, a large percentage of the back wall of the gallbladder is adherent to the liver. This seems to fixate the GB pretty well and prevent unwelcome contortionist maneuverings. as above. In the elderly, loss of fat and general atrophy of tissues may contribute. The lady felt much better afterwards. She went home in a couple days, albeit unhappy about the hospital food. The fry had been dry. Who doesn't know how to cook fish?
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