Uncommon Presentation of Xanthogranulomatous Cholecystitis in a True Gallbladder Diverticulum: A Case Report and Literature Review.

BACKGROUND The gallbladder develops from the hepatic diverticulum during the fourth week of gestation, which also give rise to the liver, extrahepatic biliary ducts, and ventral part of the pancreas. Infrequently, the gallbladder has malformation or disruption in embryogenesis, leading to congenital anomalies. There are various congenital anomalies that can arise in the gallbladder. True or congenital diverticulum of the gallbladder is a rare entity that accounts for only 0.06% of gallbladder congenital anomalies and 0.0008% of cholecystectomies at the Mayo Clinic. CASE REPORT Herein, we report a rare case of a 38-year-old woman who presented to Jubail General Hospital's surgery clinic with right upper-quadrant (RUQ) pain associated with vomiting after meals for 1 month. Laparoscopic cholecystectomy was done and gallbladder tissue was sent to histopathology. Gross examination revealed an outpouching mucosa within the wall that was proven to consist of muscularis and serosa layers under light microscope. Interestingly, xanthogranulomatous inflammation was confined to the diverticulum, unlike the chronic inflammation involving the remaining gallbladder. Based on the above findings, the diagnosis of congenital diverticulum with xanthogranulomatous cholecystitis was made. CONCLUSIONS Gallbladders associated with a true diverticulum are uncommonly found to be buried in the liver, leading to surgical difficulties during cholecystectomy. Therefore, background knowledge of occasional anomalies plays a crucial role in guiding the surgeon to choose the optimal method of management. We also discuss the associated complications that accompany these anomalies, such as non-specific prolonged ailments, acalculous cholecystitis, cholecystitis and cholelithiasis, recurrent cholangitis, and carcinoma of the gallbladder.

Laparoscopic Cholecystectomy in a Morbidly Obese Patient With Situs Inversus Totalis: A Case Report.

Situs inversus totalis (SIT) is a rare congenital condition characterized by a mirror-image transposition of both the abdominal and the thoracic organs. Due to the reversal of organs, laparoscopic cholecystectomy (LC) poses a significant challenge in patients with SIT. After the first reported case of LC in a patient with SIT in 1991, 120 more such reports have been published in the literature, but very few of them were carried out on morbidly obese patients. We report a morbidly obese patient, a known case of SIT, who presented with persistent biliary colic and underwent successful laparoscopic cholecystectomy in our institution. At surgery we used reverse Trendelenburg position with left tilt up and mirror-image of usual laparoscopic cholecystectomy port sites for the procedure. The procedure proved to be challenging, both due to the morbid obesity of the patient and the reversal of organs, which affected orientation and dexterity. A successful outcome has been reported in all the cases before us as well as our case, but it is noteworthy to mention that such cases must be performed by well-trained laparoscopic surgeons with impeccable manual dexterity who must take extreme care to avoid iatrogenic injuries.