Congenital anomalies of the gallbladder and cystic ducts

Congenital anomalies of the gallbladder and cystic ducts  were diagnosed in 1% of the cases.one gallbladder and cystic duct agenesia (0.2%); one left lobule misplacement with the insertion of the cystic duct into the left hepatic duct (0.2%); three gallbladder hypoplasias (congenital vesicle diverticula) (0.6%)

The gallbladder is a pear-shaped structure that lies on the underside of the liver in the main liver scissure at the junction of the right and left lobes of the liver. It’s 7.5- 12 cm long, with a normal capacity of approximately 25-30 ml.

It consists of the fundus, a body, and a neck that terminates in a narrow infundibulum. It’s a reservoir for bile, concentrate bile, and secrecy mucus approximately 20 ml per day.

The cystic duct is about 3 cm in length, but it’s length variable. Its lumen is usually 1-3 mm in diameter. It’s mucosa is arranged in spiral folds called as valves of Heister & the wall is surrounded by a sphincteric structure known as the sphincter of Lutkens.

Embryology

From the ventral wall of the foregut, the hepatic diverticulum arises and that elongates into a stalk to form choledochus. A lateral bud given off and thus become the fall gallbladder and cystic duct.

Congenital anomalies 
• Absence gallbladder ( agenesis):- Gallbladder is absent and if in case can’t visualize it that means not indicate a pathological problem. It’s caused by the failure of development of the caudal division of the primitive hepatic diverticulum or failure of vacuolization after the solid phase of embryonic development &  surgical incidence of gallbladder agenesis is nearly 0.02%.

• The Phrygian cap:- it’s consists 2-6 %.Most common anomalies. ”Phrygian cap” normally means hats worn by the people of Phrygia. It’s a cap-like gallbladder where there is a septum over the fundus.
• Double gallbladder :- Rarely seen, there are present two gallbladders. They can be in the following ways:- 
a. Both gallbladders arise from a common cystic duct.
B. Arises from two different cystic ducts.

• Floating gallbladder:- It may hang on a long mesentery, that makes it liable to undergo torsion and this torsion causes recurrent abdominal pain. This gallbladder is also called as mobile Gallbladder or mesenteric gallbladder because of its mesenteric attachment nature. Treatment is the removal of long mesentery so that the Gallbladder remains in its place.
•  Absent cystic duct:- No cystic duct so gallbladder is directly attached to the common bile duct. The main danger at surgery is damage to the bile duct,& thus need proper care.

• Long insertion of the cystic duct:- Gallbladder having long cystic duct with the low insertion of the cystic duct into the common bile duct near ampulla. Variation of this anomaly can occur. 
During surgery, the operating surgeon correctly identifies the anatomy in order to avoid damage to the hepatic or common bile duct. Here complete dissection of the cystic duct should not be performed because there is a potential to devascularise the common bile ducts, and that may result in structure formation.

• An accessory cholecystohepatic duct:- This is also known as duct of Luscka. It’s only present in a 10% population. Here branch of ducts passing directly into the gallbladder from the liver.
• Cystic artery may originate anteriorly:-  Cystic artery may originate from right hepatic artery or common hepatic artery.
• Moynihan’s caterpillar hump:- Most dangerous anomalies where the hepatic artery takes a toursion course on the front of the origin of the cystic duct or the right hepatic artery is tortuous & cystic artery short. This creat problem while doing cholecystectomy. Here mistakenly cystic duct gets ligated instead of ligating the hepatic artery.
• Double cystic duct:- Here two cystic ducts that join the same single gallbladder.

Diagnosis of Congenital anomalies of the gallbladder and cystic ducts

Whole blood, urine, & stool tests seeking any evidence of structural malformations, any types of blocking or inhibiting the flow of bile, or to check enzyme levels that might indicate liver disfunction & /or inflammation.
Computer tomography (CT), ultrasound, and MRI can all be used to help with diagnosis. ERCP, plain X-ray, Endoscopic ultrasonography ( EUS), Cholescintigraphy, PTC.