Is right-sided ligamentum teres hepatis always accompanied by left-sided gallbladder? Case reports and literature review
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Right-sided ligamentum teres (RSLT) hepatis is a rare anatomical variant in which the fetal umbilical vein is connected to the right paramedian trunk of the portal vein. Despite its rarity, it is crucial for surgeons and intervention specialists because of its frequent association with intrahepatic vascular and biliary anomalies. Inattention to these anomalies before intervention, especially living-donor liver transplantation, can have life-threatening consequences. The relationship between gallbladder location and RSLT is still controversial, with RSLT regarded as one of the critical features of left-sided gallbladder in most studies. According to these hypotheses, once RSLT is present, left-sided gallbladder must be found as well. Here, we report three cases in which RSLT was associated with intrahepatic portal vein anomalies. In one case, the gallbladder was left-sided, but in the other two cases, it had a normal cholecystic axis to the right of the umbilical fissure. Therefore, the relationship between RSLT and gallbladder location may require redefinition, and surgeons should be aware of vascular anomalies once RSLT has been detected, even in the absence of left-sided gallbladder or biliary anomalies.
• Right-sided ligamentum teres (RSLT) hepatis is a rare anatomical variant, which is frequently associated with intrahepatic vascular and biliary anomalies. Previous studies had discussed the vascular anomalies in livers with RSLT.
• However, no predictable correlation exists between portal vein anomalies and anomalous biliary confluences in patients with RSLT. Moreover, we found that RSLT does not always coexist with left-sided gallbladder.
• Unawareness of these vascular and biliary anomalies in liver with RSLT before intervention can have life-threatening consequences.
• Thus, the vascular and biliary variations should be surveyed in multimodality imaging studies such as dynamic CT, 3D magnetic resonance cholangiopancreatography, or digital subtraction angiography once the RSLT is detected before intervention.
KeywordsRight-sided ligamentum teres (RSLT) hepatis Left-sided gallbladder Maximum intensity projection (MIP) Magnetic resonance cholangiopancreatography (MRCP)
A left-sided gallbladder without situs inversus was first described by Hochstetter in 1886 , and a multicenter series of laparoscopic cholecystectomies has indicated a prevalence of 0.3% [7, 8, 9]. There has been much debate and controversy about the true definition of left-sided gallbladders [10, 11] and the relationship between gallbladder position and ligamentum teres. The simple definition was that of a gallbladder located on the undersurface of the left lobe, with only two theories for its development (i.e., aberrant drawing of the pars cystica toward the left or accessory gallbladder from the left hepatic duct with regression of the main gallbladder), until Nagai et al. cautioned that some reports of left-sided gallbladders may have been erroneous [10, 11]. It was proposed that, rather than the gallbladder, it was the ligamentum teres whose unusual location caused the anatomical variation. This was because, according to the limited explanation of the earlier hypothesis, a left-sided gallbladder must be located to the left of not only the round ligament but also the MHV, whereas the round ligament itself should originate from the left portal vein.
The gallbladder bud migrates to the left lobe (the portal vein, biliary tree, and hepatic artery should be in their normal position and classified as an ectopic gallbladder).
The gallbladder develops directly from the left hepatic duct, with failed development of the normal structure on the right side (cystic duct from the left hepatic duct).
The left umbilical vein disappears, whereas the right umbilical vein partly remains, with its peripheral and central portions developing into the ligamentum teres and ligamentum venosum, respectively. According to this (Matsumoto’s) hypothesis, the right umbilical portion should lie to the right of the gallbladder bed.
The ligamentum teres simply deviates to the right.
These hypotheses seek to explain the relationship between RSLT, intrahepatic portal vein anomalies, and left-sided gallbladder. All of them [1, 5, 9] imply that, once RSLT is present, a left-sided gallbladder must be found as well. However, in the cases reported by Yamashita et al. , RSLT could be present with the gallbladder located just beneath, to the left, or to the right of the round ligament. We have presented another two cases where RSLT was present without a left-sided gallbladder. The 3D MRCP and MIP reconstruction used in our cases provide objective information about portal flow and biliary confluence in RSLT livers.
RSLT is frequently accompanied by intrahepatic vascular anomalies and anomalous biliary confluences [1, 2, 5]. However, no predictable correlation exists between portal vein anomalies and anomalous biliary confluences in patients with RSLT , despite the fact that vascular anomalies in RSLT livers have been thoroughly discussed and classified [1, 2, 5]. Moreover, we found that RSLT does not always coexist with left-sided gallbladder. Consequently, the vasculature and biliary structure should be surveyed carefully in preoperative imaging studies when RSLT is detected, even in the absence of left-sided gallbladder. Inattention to such anomalies before intervention can have life-threatening consequences. Because independent ramification of the right lateral portal pedicle is the most common RSLT type, ligation of the left trunk of the portal vein during hepatobiliary surgery will disrupt portal flow in the left two-thirds of the entire liver if the common trunk of the left portal vein and right paramedian pedicle is misinterpreted as the left portal vein . Serious biliary complications during major hepatobiliary interventions in patients with RSLT have also been reported [13, 14]. The relationship between RSLT and biliary confluences may require further investigation and a redefinition. With the increasing popularity of 3D MRCP, an extremely low-risk examination that requires no contrast medium injection and only a relatively short examination time, a better understanding of biliary confluences in RSLT livers can be achieved.
This manuscript was edited by Wallace Academic Editing.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Conflict of interest
Both authors report no conflicts of interest.
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