Congenital Anomalies of the Gallbladder *

JACOB RABINOVITCH, M.D., C.M., PHINEAS RABINOVITCH, M.D., C.M.,

PHILIP ROSENBLATr, M.D., F.A.C.P., BERNARD PINES, M.D.
From the Adelphi Hospital, Brooklyn, and the Mount Royal Hospital, Montreal

MALFORMATIONS of the extrahepatic bile

passages have been emphasized by Rabinovitch et al.5 and others, but such treatises
have not included any comprehensive study
of anomalies of the gallbladder except to
state in a general way, that they do occur.
It is difficult to assess the percentage of
anomalous gallbladders that undergo pathologic changes. It is becoming increasingly
clear, however, from the growing literature
on this subject, that a fair percentage of
such anomalies produce symptoms in adult
life, often of a chronic and even bizarre nature. These anomalies, although in themselves very rare, are so often the site of
serious pathologic changes that they become important both from a clinical and
anatomic point of view. Further, malformations of the gallbladder and the complications associated with them are of such a
varied and unusual nature that they always
remain an interesting subject.
The origin of anomalies of the gallbladder has always exercised the minds and, indeed, the imaginations of a succession of
surgeons and anatomists who have chanced
upon them, but the primal source remains
in many instances uncertain. The normal
gallbladder configuration is achieved by a
unique developmental process. Its origin
can be traced embryologically to a small
hollow bud which arises from the duodenum and grows upwards into the septum
transversum. This bud subdivides into two,
of which one forms the gallbladder and
cystic duct, and the other gives rise to the
main mass of the glandular substance of
*

Submitted for publication November

7,

the liver. It is quite conceivable that any

arrest or deviation from this developmental
process may result in some malformation
of the gallbladder. Thus, there may be partial interruption in the continuity of the
gallbladder which may take the form of a
small blind end, or the interruption may
be complete and result in total absence of
the organ.
The occurrence of bizarre forms of anomalies of the gallbladder has been well
known for many years. Gross 4 in 1936
gave a comprehensive account of these
anomalies as they are seen in man and animal. Of recent years, owing to increased
interest in biliary diseases, and improvements in radiologic technics, more cases
have been observed and recorded. The
series now under review consists of 12 cases
of anomalies of the gallbladder which we
had the opportunity to observe either at
the operating table or at autopsy. The latter
cases were incidental findings during routine postmortem examination of the biliary
system. We believe that a study of these
cases is adequate to illustrate some of the
more common, and perhaps also, some of
the rarer forms of anomalies which may be
found in association with the gallbladder.
Double Gallbladder: This is perhaps one
of the more common anomalies of the gallbladder to be found in man. In this series,
three patients are included in this group.
The first patient was a 38-year-old white
woman, who was admitted to the hospital
because of recurrent attacks of right upper
abdominal pain, of eight months duration.
The pain often radiated to the back and

1957.

161

of Surgery
AnnalsAugust
RABINOVITCH, RABINOVITCH, ROSENBLATT AND PINES
162
1958
between the shoulder blades, and was associated at times with nausea and vomiting.
Physical examination on admission to the
hospital revealed a well developed and well
J,
nourished somewhat obese female, who did
I
not appear acutely ill. The abdomen was
K
m
generally soft, not distended and slightly
f
tender in the right upper quadrant; the
i
gallbladder could not be palpated. Chole- ib
cystography failed to visualize the gallbladder.
At operation, two gallbladder cavities,
approximately of the same size, were found
j
adjoining one another. It was difficult at
first to identify these as two separate structures because they were invested with a
common peritoneal fold. However, when
/
the latter was resected away it became evident that we
dealing here with two
w were
FIG. 2. Same as Figure 1 with cavities laid
dealng
desinctthats
rewere
htwih
distinct
sacs. There
were also
two cstwo
cystic
open. Both sacs contain stones and the walls are
ducts with individual openings into the thickened because of chronic inflammation. There
common bile duct, and two cystic arteries. are two cystic ducts, A and B.
Multiple stones were found in both cavities; the common duct was clean
(Fig. 1, 2).
Both sacs were removed following which
the patient made an uneventful recovery.
The second case concerned a 46-year-old
woman who was admitted to the hospital
because of frequent attacks of biliary colic;
the last attack occurred two days prior to
admission. The clinical diagnosis of cholecystitis and cholelithiasis was confirmed by
I.
_
2radiography.
At operation, two gallbladders were
found, both of about the same size, and one
slightly superimposed upon the other. The
double nature of the organ was made clear
by a deep fissure which ran between the
two sacs. The main organ showed evidence
of chronic cholecystitis and cholelithiasis,
while the accessory vesicle appeared normal and free from stones. The two cystic
ducts converged to form a single channel
which joined the common bile duct. There
was only one cystic artery which ran for a
_
_ , _
short distance along the cystic duct and
_
then divided into two, supplying a branch
FIG. 1. Photograph of double gallbladder; sacs are
of equal size.
to each sac (Fig. 3). Both gallbladders

CONGENITAL ANO'MALIES OF THE GALLBLADDER

\Vdunic 148
Number 2

simlootlh anid

wNas

wvere removed; recover!7

163

tincomplicate(l.

The third case concerned

oldl infaant ho was admitted to
ith the diagnosis of pvloric
oper-ation, in addition to the
a

strutction

fotundl

the

was

lhospital

stenosis. At

pyloric

hvpertrophv, there

double gallblladder. The

vesicle

anti

three-week-

wvas

ob-

also

accessory

som)Iewhat smaller thaini its coIl-

panIionl. 13oth sacs became confluent at their

proximilal

(Il

Cendl

and drainCed inlto onle cystic

ect (Fig,,. 4).

As hals been noted in the first case, the

trtie duiplicate niatuire of the gallbladder is
not oftecn dliscerned whenl tthe organ is first
examined. This is usually due to the investbx' a common peniImleInt of the twro
toneal coat x-whiclh hi(es them1- fromni view.
sacs

Beingr
imost uinuisuial condition, it is not
at laparotoimv. This poiint is
sllspecte(l
mlav be overlooked
stresse(l l)ecatse one
at the primantry operatioin, -an d this oversigr,ht
miax cauise confusion later on because of
a

even

sac

furtller symptoms,

aind

max

be responsible

for ina-dequate suirgery in all suiclh instances.

B3oth
mIlax be of approximn-ately the
sacs

samIle size or the 1accessory

be

considlerahl)lv

siiller

g(allbladder

tlhani

the mainl or-

repor-tedC by Gross the

mutIclch lar(ger than its compainioI. In the first txxo cases of the present
ser-ies botlh caxities xvere approximately of
gran.

In

cessorx

the

case

sac

xx'as

ac-

the samIec size, while in the third case the

accessory' gallbladder was smilaller than the

An

accessory

FI(;. 3. Diagram of douible gallbladder. The

cystic (dticts tiiuite to fonri coimmiiion clhannc l before joining the comimiioin (Iluct. Sacs of samiie size.
a

max'

gallblladder dloes nlot alwvas

assuImIle the samIle aInatoImlic positioIn. It Imax'

lie

one may

emptxy into

eitlher of the hepatic

diucts.

The cystic arterx' max' also shioxx xariatioIns in origin and distribution, aind it is
of paraimiouint importanice to bear in mind
the particuilar anatomic relationship xwhich
exists betxveen the xvessel anci the dtuctal
struictures or it imax'- be inljuired durinig suirgery' and cause considerable and uindtue
bleeding. Normally, the cystic arterx aiises
from the right hepatic artery but uinder abnormal conditions it max' take oIiginl from

under the left lobe of the liver aIi its

cx'stic (Ilct max tlhen drain into the left
hepatic (duict or it may be embedded in the
riglt lol)e of the liver ancd dr-ain into the
rIiglt lhepatic ducit. The tNx-o cystic tlicts
imax
to forimi a comimIllon clhannel
hefore thlcy join the comimonoll dulct (Y-shliped
tv'pe ), or] thley miav drain separately7 inlto

origin.

ducctal system. In the latter inlstanlce

they mav empty into the choledochus, or

logic changes oily7 oine sac

converge

the

the left hepatic, comimlonl hepatic or gastric

Cartery. There miayx be onlx' onie cxvstic artery
suipplyiing botlh sacs, or there max' be t\x'o
separ-ate ar teries xvithl different sites of

WVhein the gallbladdler uindergoes

may

patho-

becoIm1e af-

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RABINOVITCH, RABINOVITCH, ROSENBLATT AND PINES

Annals of Surgery
August 1958

FIG. 4. Diagram of double gallbladder. Accessory gallbladder somewhat smaller than main organ. The sacs become confluent at their proximal
ends and drain into a common cystic duct.

FIG. 5. Diagram of bilobed gallbladder. Extemal surface is marked by an area of constriction

in the fundus and a grooved line running along the
anterior aspect of the organ.

fected while the other remains normal; such

was the case in the second patient; the
main organ was the seat of chronic inflammation and stone formation while the accessory vesicle was normal. A similar case
was reported by Barton.2
Boyden3 in studying the occurrence of
anomalous gallbladders in animals found
23 examples of double gallbladder in 2,600
cats, 47 cases in 2,555 calves and three cases
in 2,500 lambs and sheep. He was also able
to demonstrate in vertebrate embryos a dilated structure situated at the junction of
the cystic, hepatic and common bile ducts
from which arose numerous outgrowths and
accessory vesicle formations. Under normal
conditions these supernumerary structures

regress, but should one of them persist, an

accessory gallbladder may develop. It is believed that the same holds true in the case
of man as it does in animal.
There are no pathognomonic signs or
symptoms of double gallbladder. Diagnosis
is practically dependent on investigations,

especially radiography. Cholecystography

with the aid of the dye will reveal the

anomaly present in most instances.
Bilobed Gallbladder: This is one of the
rarer forms of anomalies of the gallbladder
to be found in the human. We have observed two such cases at autopsy; both
were incidental findings during routine post
mortem examination of the biliary tract.
When first viewed, a bilobed gallbladder

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CONGENITAL ANOMALIES OF THE GALLBLADDER

FIG. 6. Same as Figure 5 with the sac opened.

There is a median longitudinal septum dividing the
gallbladder into two cavities. There are two cystic
ducts with individual openings into the common
bile duct.
appears as a

normal structure to external

examination. The anomaly is discerned only

after the sac is opened; the latter is then

found to be divided by a median partition

into two chambers. The two cavities frequently communicate at their proximal
ends and drain into a common duct.
The first case of a bilobed gallbladder in
this series concerned a 22-year-old male
who died of an endothelioma of the iliac
bones with wide spread metastases to the
viscera. At autopsy, aside from the malignant lesion in the bones and viscera, there
was also found a bilobed gallbladder. The
external surface was marked by an area of
constriction at the summit of the fundus.
From this point a grooved line could be
traced along the anterior aspect of the gall-

165

FIG. 7. Bilobed gallbladder. There

tic ducts which unite to form

(Y-shaped) before joining the

are two cysa common channel

common bile duct.

bladder and terminate at its proximal end

(Fig. 5). When the gallbladder was opened
it was found divided into two compartments by a longitudinal septum. Each
chamber opened into a small cystic duct;
the latter opened separately into the common bile duct (Fig. 6). There was only one
cystic artery supplying the gallbladder.
The second case concerned a 48-year-old
man whose death was unrelated to the
anomaly found in the gallbladder. At autopsy, the gallbladder was found divided
into two sacs by a median partition. There
were two cystic ducts which became confluent close to their union with the common
bile duct (Fig. 7); there was only one
cystic artery.
Boyden found that the bilobed gallblad-

166

RABINOVITCH, RABINOVITCH, ROSENBLATT AND PINES

FIG. 8. Diagram of vestigial gallbladder. One

is common duct and two is small vesicle which
communicates with the common bile duct.

der was the most common anomaly in

cat. He observed it 272 times, or in ten
cent of all the animals examined. In the

the
per

humlan, however, this is one of the rarer

anomalies to be found in relation to the
gallbladder.
The origin of the bilobed gallbladder
may be traced to the embryonic solid stage
through which this structure passes. The
longitudinal septum undoubtedly represents an incomplete resolution of this solid
stage. Thus, instead of the entire cavity being again re-established, a portion of the
solid constituents remain to form a median
partition.

Vestigial Gallbladder: It has been already stated in the introduction that partial
interruption in the continuity of the gallbladder may occur during early embryonic
life and give rise as a result to a small, blind

Annals of Surgery
August 1958

Fic. 9. Diverticulum-shaped gallbladder with

absence of cystic duct. There is a wide opening

between the vesicle and the bile duct. One is common bile duct and two is gallbladder.

vesicle, a relic of the primitive bud; the latbody is frequently associated with the
bile duct. One or several of these vesicles
may persist through post embryonic life.
Such rudimentary structures have been recognized in association with developmental
anomalies of the biliary system in lower
animals. It is our purpose to record a somewhat similar case in the human.
The patient was a 15-year-old girl who
died of Hodgkins disease. At autopsy, examination of the biliary system disclosed
the presence of a small vesicle which replaced the normal gallbladder. It measured
about one cm. in diameter and was closely
related to the common bile duct (Fig. 8).
When opened it was found to communicate
with the bile duct and presented a picture
characteristic of gallbladder mucosa. No
doubt, this rudimentary structure represents
ter

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CONGENITAL ANOMALIEES OF THE GALLBLADDER

an early arrest in the growth of the gallbladder. A closely similar case of vestigian
gall bladder was described by Banks and
Lawrance.1 They found on the right side
of the bile duct at the porta hepatis a small
body, one cm. in diameter; this body did
not communicate with the duct, and on section it presented a picture characteristic of
gallbladder mucosa.
Diverticulum-like Formation of the
Gallbladder with Complete Absence of the
Cystic Duct: This terminology, we believe,
is thoroughly satisfactory provided attention is directed solely to the dilated, diverticulum-like appearance of the gallbladder
and absence of the cystic duct. Though descriptively correct, it throws the emphasis
on the gross appearance of the organ rather
than on its histologic structure. As the name
implies, the gallbladder in this anomaly assumes a spherical shape instead of the usual
pear-shaped appearance. It communicates
directly with the bile duct through a wide
orifice, there being complete absence of
Hartmann's pouch and cystic duct. When
first viewed the gallbladder resembles a
diverticulum of the bile duct for which it
may be readily mistaken. However, its distinctive anatomic features which can be
confirmed by any careful observer, establishes the correct diagnosis. One such anomaly was found in the present series. It concerned a 42-year-old man who was admitted to the hospital because of frequent
attacks of biliary colic of several years duration. The diagnosis of biliary stones was
confirmed by radiography. At operation, the
gallbladder consisted of a small, spherical
body, about four cm. in diameter. It communicated directly with the common bile
duct through a wide orifice and gave the
impression of being a diverticulum of the
common bile duct, a condition not infrequently encountered in this location. There
was no Hartmann's pouch or cystic duct
(Fig. 9). When opened, the mucosa was
thrown into folds, a picture distinctive of
gallbladder mucosa. Numerous calculi were

167
found both within the gallbladder and the
common duct.
The patient presented a rather difficult
problem in surgical management largely
because of the absence of the cystic duct
and the wide communication which existed
between the gallbladder and the bile duct.
The operative procedure consisted first, in
the removal of all stones and second, in excising an adequate segment of the wall of
the gallbladder and reconstruction of the
bile duct. Great care was taken not to impinge on the lumen of the duct during this
procedure. A T tube was then inserted
through an opening left in the duct and the
abdominal wall was closed in layers. Recovery was uneventful.
The diagnosis and manageemnt of the
anomaly just described often presents a difficult surgical problem. Recognition by radiography will depend on the association of
the condition with a functioning gallbladder, and recognition by the surgeon will
depend on his knowledge of the anatomy
and pathology of the parts involved. The
technical difficulties encountered in the operation may be unsurmountable, largely
because of absence of a cystic duct and the
wide orifice between the gallbladder and
the bile duct. Great care and skill is necessary, therefore, in the handling of this
condition if any complications are to be
avoided.
Absence of the Gallbladder: Congenital
absence of the gallbladder is a rare condition,
seldom intruding into surgical practice. The
condition is much more frequent, however,
if we consider those cases which are associated with atresia of the extrahepatic bile
passages. It has been estimated that absence of the gallbladder occurs in about
one-sixth of cases with atresia of the bile
ducts. The literature testifies that the condition is compatible with normal life, and
that the anomaly is not accompanied by
compensatory dilatation of the bile ducts.
The etiology of this anomaly is best explained by adherence to the accepted fact

168

RABINOVITCH, RABINOVITCH, ROSENBLATT AND PINES

that the gallbladder develops as an offshoot

of the hepatic diverticulum. Failure of this
embryonic body to subdivide will result in
absence of the gallbladder. The condition
may also be caused by failure of the embryonic bud to resolve from its solid stage
to form a hollow organ.
There were five cases with complete absence of the gall bladder in the present
series; they were all incidental findings discovered at autopsy. The ages of the patients
in this series were 11 months, 21 months, 22
years, 55 years and 83 years, respectively.
In the case of the 21-month-old infant there
was found, in addition to absence of the
gallbladder, atresia of the major hepatic
ducts. It is of interest to note that all of
the patients in this series were males. These
anomalies do not as a rule present clinical
problems unless the patient shows symptoms which mimic gallbladder disease.
Cholecystography will fail of course to
visualize the gallbladder in such instances
and will give an erroneous impression of
a non-functioning or diseased gallbladder.
This may somtimes lead to unnecessary surgery unless the condition is borne in mind.

of Surgery
AnnalsAugust
1958

Summary
Twelve cases are reported with anomalies
of the gallbladder. The cases raise some
points of interest in the development, detection and surgical management of some
of these anomalies. The characteristic anatomic appearance of each anomaly is described and its clinical and surgical significance generally discussed.
Acknowledgment
We are indebted to Miss Marjorie Passano for
the drawings used in this paper.

Bibliography
1. Banks, P. J. and K. Lawrance: A Case of Vestigial Gallbladder. Brit. Med. J., p. 1254,
1955.
2. Barton, P. B.: Double Gallbladder with Calculi
in One. Radiography and Photography, 31:
127, 1955.
3. Boyden, E. A.: The Accessory Gallbladder: An
Embryological and Comparative Study of
Aberrant Biliary Vesicles Occurring in Man
and the Domestic Animals. Am. J. Anat., 38:
177, 1926.
4. Gross, R. E.: Congenital Anomalies of the Gallbladder. Arch. of Surgery, 32:131, 1936.
5. Rabinovitch, J., P. Rabinovitch and H. J. Zisk:
Rare Anomalies of the Extrahepatic Bile
Ducts. Ann. of Sur., 144:93, 1956.