successful laparoscopic treatment has been described previously in only a few cases . rarely the diagnosis is suspected preoperatively when using only ultrasound .
other diagnostic tests like magnetic resonance cholangiopancreatography ( mrcp ) , endoscopic retrograde cholangiopancreatography ( ercp ) and intraoperative cholangiogram can be more accurate in the diagnosis of this condition .
intraoperative cholangiogram represents a powerful tool for the surgeon when dealing with double gallbladder , it help to delineate the anatomy and confirms the diagnosis .
( 1,2 ) we present a case report of a patient with symptomatic cholelithiasis with double gallbladder treated laparoscopically using intraoperative cholangiogram .
a 21 year old male otherwise healthy with no previous surgical history , presented to the emergency room with the chief complaint of several hours of right upper quadrant pain that started after a large meal .
the patient described a history of several weeks of right upper quadrant pain after meals but normally it would subside without any intervention . on admission ,
the patient had normal and stable vital signs and on physical exam there was tenderness to palpation on the right upper quadrant but no peritoneal signs .
his laboratory exams were unremarkable with a normal white blood cell count and normal liver function test .
the patient was admitted to the hospital and he was taken to the operating room where he underwent a laparoscopic cholecystectomy using the standard 4 port technique with intraoperative cholangiogram ( fig 1 ) .
also appreciated in the image : the common bile duct , the common hepatic duct and the left and right hepatic ducts . during the operation
( fig 23 ) the intraoperative cholangiogram helped to identify each cystic duct and the operation was otherwise uneventful .
he was started on clear liquid diet postoperatively and he was discharged home on postoperative day one .
gallbladder duplication is a very rare diagnosis . even though the true incidence reported during autopsy is about 1:40005000
the gallbladder primordium can split and form a gallbladder duplication but this only represents a congenital anomaly of the gallbladder .
true gallbladder duplication has two cystic ducts and two cystic arteries . the true double gallbladder forms from an extra primordium during the embryonic development .
the symptomatic patient with two gallbladder represents a diagnostic and treatment challenge to the general surgeon.(13 ) to aid in the diagnosis the surgeon can use ultrasound , mrcp , ercp and ultrasound .
none of these tools are 100% sensitive and only in little more than 50% of the cases the diagnosis is made preoperatively.(2,3 ) in our case the ultrasound was questionable but certainly prompted the use of intraoperative cholangiogram to help define the anatomy . in figure 2 two cystic ducts can clearly be seen which makes our case a true gallbladder duplication treated successfully with standard laparoscopic technique .
the differential diagnosis of a gb duplication seen in us is large , but the most common diagnosis are a phrygian cap , gallbladder diverticulum or a choledochal cyst.(3 ) once the diagnosis has been made by seen two cystic ducts in the symptomatic patient , the surgical removal of both gallbladders is indicated .
there are only a few case reports of double gb successfully managed laparoscopically in the literature.(3 - 7 ) our case shows that the use of intraoperative cholangiogram confirms the diagnosis and helps to identify both cystic ducts .
previous literature have shown conflicting and controversial results when trying to use intraoperative cholangiogram to prevent bile duct injuries , but there no large series or randomized studies evaluating the use of intraoperative cholangiogram in patients with double gallbladder .
( 8 - 10 ) we recommend routine use of ioc when dealing with abnormal anatomy or congenital anomalies of the gallbladder .
the evidence is anecdotal but as shown on this case report clearly seen two cystic ducts accurately diagnosed a gallbladder duplication and prevented the surgeon from leaving an unidentified gallbladder which later can become a diagnostic enigma .
 double gallbladder is a rare finding in patients with symptomatic cholelithiasis or acute cholecystitis . 
 the incidence has been described as 1 in every 4000 - 5000 patients during autopsy . to identify the gallbladder ( gb ) duplication prior to surgical removal of the gb 
 is of upmost importance . 
 it is not unusual to identify this diagnosis intraoperatively , but by using us , ercp or mrcp more than 50% of the cases are diagnosed preoperatively . 
 the use of intraoperative cholangiogram helps to identify the anatomy and confirm the diagnosis during laparoscopic cholecystectomy in patients with gallbladder duplication . 
INTRODUCTION
CASE REPORT
DISCUSSION