few similar cases are reported in literature but none of them is associated with mirizzi syndrome .
radiological images could help the surgeon to choose the surgical strategy and to evaluate the presence of associated diseases . in our case
laparoscopic surgery showed to be an excellent approach for both the cholecystectomy and the repair of the defect of the abdominal wall .
the patient was an 85 year - old man with history of hypertension , previous surgery for perforated diverticular disease ( hartmann procedure followed by reversal of colostomy ) .
the physical examination showed a 5 cm mass in the right upper quadrant tender to palpation .
ultrasound and ct confirmed the presence of a lithiasic gallbladder herniated through the abdominal wall ( fig.1 ) , with a dilatation of the common bile duct that measured 11 mm , due to a 17 mm obstructive infundibular stone as it happens in mirizzi syndrome type i ( fig.2 ) .
lithiasic gallbladder herniated through the abdominal wall the routine complete blood test , including bilirubin level , was unremarkable .
therefore the patient underwent a laparoscopic cholecystectomy and a repair of the hernia . during surgery , multiple adhesions were found and released carefully to identify the gallbladder that was fully included in the right upper quadrant abdominal wall covered by peritoneum .
the gallbladder was completely released and the dissection of the pedicle showed a short cystic duct and a normal common bile duct .
most of the cases reported in literature are internal hernias through the winslow foramen ( 1 ) .
the herniation of the gallbladder through acquired defects of the abdominal wall ( incisional hernia ) has been much less reported .
( 2 ) presented the case of a gallbladder herniated through a fascial defect of a subcostal incision .
garcia reported a patient who presented a gallbladder hernia through a parastomal defect ( 3 ) .
more recently , the case of a gallbladder strangulation through an abdominal wall defect on the site of a previous colostomy was described ( 4 ) . in this case
, the most remarkable thing is that herniation does not occur through a natural orifice or an acquired defect , such as respectively for the winslow foramen or for an incisional hernia , but directly into the abdominal wall . to our knowledge
, there are only 3 published cases of spontaneous herniation of the gallbladder through the abdominal wall ( 5,6,7 ) .
another interesting aspect of this case is the presence of a chronically distended gallbladder ( gallbladder hydrops ) , associated with extrinsic compression of the common hepatic duct by an impacted stone in the infundibulum ( mirizzi syndrome type i ) ( 8) .
it is probably the gallbladder dilatation that plays an important role in the development of the hernia pressing constantly the gallbladder against the abdominal wall .
usually the clinical picture is represented by a right upper quadrant pain , associated with variable degrees of a compromised general condition . in our experience
the preoperative study based on computed tomography is essential for the diagnosis of the gallbladder hernia , and it provides also additional information on the abdominal wall defect .
the management of this type of hernia consists in reducing the content and repairing the abdominal wall defect . in this case
we suggest the laparoscopy as surgical approach of first choice because it allows to solve three problems at the same time : first , the reduction of the gallbladder s incarcerated hernia ; second , it enables to perform a cholecystectomy that was indicated for the presence of gallstones and hydrops ; third , it allows to repair the hernia defect preferably with a mesh , if the local conditions are favorable . in our experience ,
preoperative imaging has been proved to detect the gallbladder disease and the morphology of the fascial defect .
mesh repair is the gold standard for hernias ; however , acute cholecystitis still remains a contraindication for mesh repair due to the high risk of infection .
 a gallbladder incarcerated hernia associated with mirizzi syndrome is a very rare entity and to our knowledge this is the first case ever described in literature . an 85-year - old man presented at the emergency department with a tender right upper quadrant mass . 
 computed tomography ( ct ) revealed the presence of a gallbladder lithiasis with signs of acute cholecystitis , herniated through the abdominal wall with an associated mirizzi syndrome . 
 laparoscopic cholecystectomy and repair of the abdominal wall defect were performed . 
 the patient recovered very well and the postoperative period was uneventful . 
INTRODUCTION
CASE PRESENTATION
DISCUSSION