Successful laparoscopic management of duplicate gallbladder: A case report and review of literature

IntroductionGallbladder duplication is a rare congenital anomaly. Recognition of this anomaly and its various types is important since it can complicate a simple hepatobiliary surgical procedure.Presentation of caseWe report a case of a 42 year old female who presented a 6 year history of intermittent right upper quadrant abdominal pain. Her basic blood investigations including liver function tests were normal. Pre-operative imaging revealed a cystic lesion communicating with biliary tree representing duplicated gallbladder. She subsequently underwent successful laparoscopic cholecystectomy. The operative challenges were more than those anticipated at the usual laparoscopic gallbladder procedures. After six months follow up the patient remained asymptomatic.DiscussionPreoperative diagnosis plays a crucial role in planning surgery, and preventing possible biliary injuries or re-operation if accessory gallbladder has been overlooked during initial surgery. Magnetic resonance cholangiopancreatography (MRCP) is the imaging modality of choice for suspected duplicate gallbladder. Laparoscopic cholecystectomy for duplicate gallbladder is a challenging operation and should be performed with meticulous dissection of the cysto-hepatic triangle.ConclusionGallbladder anomalies should be anticipated in the presence of a cystic lesion reported around the gallbladder. The laparoscopic cholecystectomy remains feasible for intervention and should be done by an experienced laparoscopic surgeon.     

Right sided spleen laying retro-duodenal: A case report and review of the literature

IntroductionUnlike left sided accessory spleen that are seen in 10–30% of cases at autopsy, cases of right accessory spleens are extremely rare. This congenital body of healthy splenic tissue simulates tumors from neighboring organs and presents a challenge in formulating a differential diagnosis.Presentation of caseWe present the case of a patient whose CT scan of the abdomen showed a large mass, 11 × 8 cm, arising retro-duodenal and lying just anterior to the right kidney. To the best of our knowledge, this is the only case where the accessory spleen was found retro-duodenal, directly anterior to the kidney and completely separate from the supra-renal gland. The chief complaint of the patient was right upper quadrant pain, radiating to the back, and colicky in nature. The patient was diagnosed with duodenal gastro-intestinal stromal tumor and a retro-peritoneal sarcoma. The mass was removed via a Kocher’s incision and immunohistological examination showed that it was a right sided accessory spleen. The patient’s left sided spleen appeared normal.DiscussionEfforts to distinguish an accessory spleen from a retroperitoneal tumor with available scans, percutaneous biopsy or biochemical tests are inconclusive. Differential diagnosis between a retroperitoneal tumor and an accessory spleen can only be made after surgical exploration.ConclusionThis case highlights the fact that surgeons should consider the possibility of an accessory spleen when making a differential diagnosis of retroperitoneal tumors.     

Branching of mandibular canal on cone beam computed tomography images

BackgroundMandibular neurovascular canal contents may be vulnerable to damage during mandibular surgical procedures. Greater knowledge of the location and configuration of the mandibular canal can help in the safe performance of these procedures in the dental clinic. Cross-sectional CBCT imaging is a good modality for studying the course, location, configuration and accessory branches of the mandibular canal. The aim of this study was to observe the branching of the mandibular canal at different segments of the mandible and mandibular tooth groups.MethodsCBCT images of 116 mandibular halves were included in this study. The presence of secondary branching of the mandibular canal in the ramus, retromolar area, molar and premolar teeth as well as the length, diameter and angle of these branches were observed.Resultssixty nine mandibular halves (59.5%), had a main canal with no branching, There were 36 IAC (31%) with one, 8 (6.9%) with two, 2 (1.7%) with three and 1(0.9%) with 5 accessory branches. Of these secondary branches, 16 (25.4%) were in the ramus, 16(25.4%) in the retromolar, and 31(49.2%) in the molar regions.ConclusionAdvanced cross-sectional imaging modalities especially CBCT is a suitable tool for observing anatomic characteristics of mandibular canal to preserve this vital structure in surgical procedures.     

Management of accessory renal arteries during aneurysm repair in a patient with end-stage renal failure

The presence of accessory renal artery is a frequent anatomic variation that can challenge abdominal aortic aneurysm (AAA) repair. Here, we show an image of an abdominal aortic aneurysm extended to multiple accessory renal arteries in a patient known for an end-stage renal failure. This case raises the questions of the criteria that should be taken in consideration for an optimal management of accessory renal artery during AAA repair.     

A curious lobe

A case of azygos lobe is presented. An azygos lobe is an accessory lobe of the lung that may occasionally be confused with a pathological process such as a bulla, lung abscess or neoplasm. Its pathogenesis is discussed, as are the characteristic x-ray features that enable an accurate diagnosis.     

Traumatic common hepatic artery injury causing isolated right hepatic ischemia due to a left accessory artery. A case report

IntroductionHepatic arterial liver flow is renowned for its redundancy. Previous studies have demonstrated that the common hepatic artery is not essential for liver survival. We present a case of a 31year-old involved in a high-speed motor vehicle accident whose liver survived thanks to the presence of an accessory hepatic artery.Presentaton of the caseWe present the case of a 31year-old male who sustained a traumatic injury of the proper hepatic artery following a motor vehicle accident. The patient suffered temporary right liver lobe ischemia due to the presence of an accessory left hepatic artery. This resulted in the selective formation of ‘biliary lakes' distinctively within the territory of the right hepatic artery supply.Simultaneously the patient developed a pseudo-aneurysm of the proper hepatic artery which required radiology intervention. At the time of pseudo-aneurysm embolisation, a rich network of arterial collaterals had formed between the accessory left hepatic and the inferior phrenic artery. On follow up the biliary lakes to the right lobe had resolved, but a small area at the periphery of the right lobe had encountered atrophy.DiscussionThis case report is an ‘in vivo’ demonstration of liver resilience to arterial flow re-distribution and demonstrates the ability of the biliary epithelium to recover from and ischemic injury.ConclusionParenchymal liver survival is mostly independent from flow within the common hepatic artery. Acute and chronic liver parenchyma changes following interruption of hepatic artery flow can still occur.     

双大头电极间放电成功消融后间隔旁道(附一例报告)

报道１例采用在双大头电极之间放电成功消融后间隔旁道的病例。该例有心动过速病史８年，特殊检查未见心脏结构异常。心电图示显性Ｂ型预激。心内标测为连接左房与右室的后间隔旁道。采用常规单大头电极分别在三尖瓣环右房侧、二尖瓣环左室侧及左房侧反复放电均未成功。改用与单大头电极放电相同位置的三尖瓣环右房侧与二尖瓣环左室侧的双大头电极之间放电，功率１５Ｗ、阻抗９８Ω，放电３ｓ后ｄｅｌｔａ波消失，巩固放电至９９ｓ而获得成功。此例说明，在单大头电极放电失败后采用在双大头电极之间放电可以进一步提高导管射频消融后间隔旁道的成功率