Biliary System
Last updated (28 October 2003)
Good Stuff
Spot Diagnosis
Biliary System
Padding space Perforated Gallbladder
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Perforated Gallbladder Click on the image to download a larger version
This lady was admitted with a 4 day history of severe upper abdominal pain. She was tender in the right upper quadrant with a positive Murphy's sign. An ultrasound of the right upper quadrant confirmed the clinical suspicion of symptomatic cholelithiasis. There was ultrasonographic evidence of a thickened gall bladder wall with a single large gallstone seen impacted in Hartman's pouch.
She was initially treated conservatively, but then had to undergo an emergency laparotomy.
The image shows the intraoperative findings, what is seen?
What complication has occurred?
Image taken at laparoscopic surgery
An upper midline incision
A mini laparotomy
Acute gangrenous cholecystitis
A hole in the gallbladder

The answer

This image shows an intra operative image of a patient with a right subcostal incision. Deep to the fascia the liver is seen with the gallbladder attached to its inferior surface. A hole is seen in the gallbladder adjacent to the sucker.

The patient has developed a perforated gallbladder.

What the student may say

This image shows a patient with a right subcostal incision, as is commonly used for open cholecystectomy. A hole leaking bile is visible in the gallbladder. The patient has developed a perforated gallbladder.

Small print

This image is not taken at the time of laparoscopic surgery. The patient may have had a laparosopy beforehand but the image is take at open surgery.

The incision is a right subcostal incision, not a midline incision. This incision is often termed a Kocher incision after the famous surgeon. An upper midline incision may be used to remove the gallbladder and is best suited to people with a narrow costal angle.

This is not a mini laparotomy, the incision is too big.

This is not gangrenous cholecystitis in the usual meaning of the term. There is a small area of gangrene but most of the gallbladder is healthy. Gangrenous cholecystitis, occurs mainly in diabetics, in whom the progress of the cholecystitis may be rapid and fulminant.

Adrian P. Ireland