CASE REPORT

Floating gallbladder strangulation caused by the lesser omentum:report of a case

Yasuyuki Miyakura • Ai Sadatomo • Makoto Ohta •

Alan T. Lefor • Naohiro Sata • Naoyuki Nishimura •

Takashi Sakatani • Yoshikazu Yasuda

Received: 8 November 2010 / Accepted: 5 July 2011 / Published online: 31 March 2012

� Springer 2012

Abstract Strangulation of the gallbladder by the omen-

tum is extremely rare. We report what to our knowledge is

only the second documented case of strangulation of a

floating gallbladder by the lesser omentum. A 61-year-old

Japanese woman presented to a local hospital after the

sudden onset right upper quadrant pain. Her clinical fea-

tures suggested a gallbladder volvulus, and the patient was

referred to our hospital for investigation and treatment.

Ultrasonography and computed tomography showed no

cholecystolithiasis, but the fundus and body of the gall-

bladder were markedly swollen without wall thickening,

whereas the neck of the gallbladder was normal. A nar-

rowed, twisted area was seen between the body and neck of

the gallbladder. Based on these findings, gallbladder vol-

vulus was diagnosed and she underwent emergency lapa-

roscopic cholecystectomy. The fundus and body of the

gallbladder were grossly necrotic. The narrowest part of the

gallbladder was tightly strangulated by the lesser omentum,

but the gallbladder neck was normal. Histopathologic

examination of the resected gallbladder showed ischemic

changes in the wall of the fundus and body. This case

highlights that the clinical features and imaging findings of

a gallbladder strangulated by the lesser omentum are sim-

ilar to those of gallbladder volvulus and that a positive

outcome is dependent on a correct diagnosis and prompt

surgical management.

Keywords Strangulation � Floating gallbladder �Lesser omentum

Introduction

Strangulation of the gallbladder is an unusual event [1–3]

associated with a floating gallbladder: a gallbladder char-

acterized by minimal attachments to the liver bed [1].

Volvulus of the gallbladder is defined as rotation of the

gallbladder on its mesentery along the axis of the cystic

duct and artery, and is a major cause of strangulation of a

floating gallbladder [4, 5]. However, strangulation of a

floating gallbladder associated with the omentum has only

ever been reported once before in the English literature [1].

We report what to our knowledge is the second case of

strangulation of a floating gallbladder caused by the lesser

omentum.

Case report

A 61-year-old Japanese woman was taken to a local hos-

pital following the sudden development of right upper

quadrant pain with nausea and vomiting. She had no his-

tory of abdominal surgery. Abdominal ultrasonography

(US) showed swelling of the fundus and body, but not of

Y. Miyakura (&)

Division of Endoscopy, Jichi Medical University,

3311-1 Yakushiji Shimotsuke, Tochigi 329-0498, Japan

e-mail: miyakura@jichi.ac.jp

Y. Miyakura � A. Sadatomo � M. Ohta �A. T. Lefor � N. Sata � Y. Yasuda

Department of Surgery, Jichi Medical University,

3311-1 Yakushiji Shimotsuke, Tochigi 329-0498, Japan

N. Nishimura

Department of Gastroenterology, Jichi Medical University,

3311-1 Yakushiji Shimotsuke, Tochigi 329-0498, Japan

T. Sakatani

Department of Pathology, Jichi Medical University,

3311-1 Yakushiji Shimotsuke, Tochigi 329-0498, Japan

123

Surg Today (2012) 42:693–696

DOI 10.1007/s00595-012-0171-3

the neck of the gallbladder. She was referred to our hospital

for surgical treatment of suspected volvulus of the gall-

bladder. On physical examination, we noted marked ten-

derness in the right upper quadrant with guarding, a

temperature of 37.2 �C, pulse rate of 68, respiratory rate of

18, and blood pressure of 180/78 mmHg. Laboratory data

showed a white blood cell (WBC) count of 11500/mm3,

and blood chemistry values within normal limits. On

abdominal US, the gallbladder appeared as two separate

compartments, without cholecystolithiasis. The fundus and

body of the gallbladder were very swollen without wall

thickening, while the neck of the gallbladder appeared

normal. Abdominal computerized tomography (CT) also

revealed a swollen fundus and body of the gallbladder

inferior to the liver, whereas the neck was normal (Fig. 1a).

A narrowed and twisted area was seen between the body

and neck of the gallbladder (Fig. 1b). Wall enhancement of

the fundus and body of the gallbladder was slightly reduced

by contrast-enhanced CT. However, a necrotic wall was

not detected preoperatively. We diagnosed volvulus of a

floating gallbladder and performed emergency laparoscopic

surgery 13 h after the initial manifestation. The mesentery

covered only the neck of the gallbladder, indicating a

floating gallbladder. The swollen fundus and body of the

gallbladder were grossly necrotic. The tip of the lesser

omentum had wrapped around the border between the body

and neck of the floating gallbladder from the underside

with a turn, adhered to itself and tightly strangulated the

gallbladder, whereas the neck was normal (Fig. 2). Thus,

the lesser omentum was the cause of the strangulation.

Laparoscopic cholecystectomy was completed success-

fully. Macroscopically, the wall of the fundus and body of

the gallbladder was black, but there were no stones or

tumors (Fig. 3a). Histological examination of the gall-

bladder revealed partial necrosis of the epithelium with

edema and hemorrhage in the lamina propria (Fig. 3a).

These findings indicated rapid ischemic changes. The

postoperative course was uneventful.

Discussion

We reported an extremely rare case of strangulation of the

gallbladder by the lesser omentum. The fact that the mes-

entery covered only the neck of the gallbladder indicated

that it was a floating gallbladder. The tip of the lesser

omentum was adhered to and wrapped around the neck of

this floating gallbladder (Fig 2).

A floating gallbladder can easily twist at the level of

attachment to the liver bed. Furthermore, an attached lesser

omentum can be stretched by movement of the floating

gallbladder and physical factors such as sudden changes

of body position and intraperitoneal pressure. Both the

floating gallbladder and the lesser omentum contributed to

the strangulation and resulted in acute ischemic cholecys-

titis requiring emergency surgical intervention. Our search

of the English literature found only one similar case [1], in

which acute cholecystitis was caused by strangulation of a

floating gallbladder by the lesser omentum. The clinical

features and pathological findings of this case revealed

repeated episodes of acute cholecystitis, indicating

incomplete obstruction and strangulation of the gallblad-

der. The authors of that case report concluded that repeated

mild fundic cholecystitis, rather than acute ischemic cho-

lecystitis, may have developed. In the present case, the

Fig. 1 Axial (a) and coronal images (b) were obtained with contrast-

enhanced computed tomography. The swollen fundus and body of the

gallbladder were located inferior to the liver. The neck of the

gallbladder appeared normal. A narrowed area with apparent

twisting (white arrow) was noted between the body and neck of the

gallbladder

694 Surg Today (2012) 42:693–696

123

lesser omentum contributed to strangulation of the floating

gallbladder, leading to acute ischemic cholecystitis. The

lesser omentum was wrapped around the neck of the

gallbladder and may have completely interrupted the blood

supply and bile flow.

Establishing a preoperative diagnosis of strangulated

gallbladder by the omentum would be extremely difficult

because the clinical symptoms, signs, and laboratory find-

ings are similar to those of acute cholecystitis. Moreover,

although US and CT can provide important information,

such as the image of a gallbladder divided into two com-

partments without cholecystolithiasis [1], this is also

indicative of volvulus of a floating gallbladder. A delay in

the diagnosis and treatment of acute ischemic cholecystitis

may be life-threatening; thus, an appropriate diagnosis and

emergency surgical resection are imperative.

We performed laparoscopic cholecystectomy success-

fully in this patient, without any requirement for open

exploration. Laparoscopic cholecystectomy for a strangu-

lated gallbladder based on a floating gallbladder is not

difficult, because the neck of the gallbladder is not

inflamed and the gallbladder is connected to the liver bed

only by short mesentery [6, 7]. Strangulation of the gall-

bladder remains a benign condition if diagnosed rapidly

and treated appropriately. A laparoscopic approach should

be the first choice when a strangulated gallbladder is

suspected.

In conclusion, the clinical features and imaging findings

of a strangulated gallbladder by the lesser omentum are

similar to those of volvulus of the gallbladder. Appropriate

diagnosis and prompt surgical treatment are essential for a

positive outcome.

Conflict of interest We have no conflict of interest or a financial

relationship with the organization that sponsored this research.

Fig. 2 Intraoperative view showing an apparently necrotic and

swollen fundus and body of the gallbladder. The white arrow shows

the area of strangulation (a, b)

Fig. 3 Macroscopic (a) and low-powered microscopic view (b) of

the gallbladder. The narrowest portion of the gallbladder (whitearrow) was tightly strangulated by the lesser omentum, but the neck

was normal (a). The mucosa had almost peeled away and edema and

hemorrhage were seen in the lamina propria (b)

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