Thanks for explaining to me your point of view, as agenesis of
gallbladder is a rare congenital condition occurring in 13 to 65 per 100,000
population, it was important to fulfill the criteria I have mentioned in my
previous posting to distinguish it from ectopic or missing gallbladder. The
following two facts are important when we are dealing with the situation of
1- The cystic duct almost always opens to the right side of CBD, regardless
of the position of gallbladder.
2- Although cholangiogram is an essential step in the diagnosis of missing
gallbladder, it is by no means 100% accurate in the diagnosis, as non
visualisation of the gallbladder does not necessarily means its absence but
it simply means non filling of the gallbladder. In ERCP it is not uncommon
not to be able to visualize the gallbladder, even with deep cannulation of
CBD and high pressure of dye injection. As surgeons we may not be aware of
this point, as we always do operative cholangiogram to visualize the biliary
tree and not the gallbladder.
For these two points it is an important step to dissect the CBD
after doing cholangiogram. By dissection I mean inspection of the RIGHT side
of CBD from the upper border of pancreatic head to the porta hepatis, the
level of its division. There is no need to dissect into the pancreas or
liver, also there is no need to skeletonise the CBD completely endangering
its blood supply.