Diagnosis of accessory liver lobe torsion on diagnostic laparoscopy: an important differential in the absence of imaging findings

Andy Liang; Hritik J. John

doi:10.18203/2349-2902.isj20263860

Authors

Andy Liang Department of Paediatric Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
Hritik J. John Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia

DOI:

https://doi.org/10.18203/2349-2902.isj20263860

Keywords:

Case report, Accessory liver lobe torsion, ALL torsion, Diagnostic laparoscopy, Paediatric

Abstract

Accessory liver lobe (ALL) torsion is a rare differential for the acute abdomen that is usually first considered with positive imaging findings. We present a case of accessory liver torsion as a cause for an acute abdomen without findings on ultrasound. A 9-year-old female presented with 3 days of right sided abdominal pain. Her vitals were within normal limits, and the patient demonstrated voluntary guarding over the right lower quadrant and right flank on exam. Bloods showed a C-reactive protein of 25.6, however other bloods including a full blood count, kidney and liver function tests were unremarkable. An abdominal ultrasound was performed which showed reactive right iliac fossa lymph nodes and probe tenderness. The patient’s pain escalated and became generalised prompting a diagnostic laparoscopy which revealed a pedunculated dark red 5×6×1 cm mass on the posterior surface of the liver. This was resected via diathermy. Histology showed haemorrhagic necrosis with associated granulation tissue consistent with infarction. Post operatively, the patient developed a port site wound infection that was drained and treated with oral antibiotics. The patient is pain-free 2 months post operatively. It is important to consider torsion of the ALL as a differential diagnosis for the acute abdomen, even in the absence of definitive imaging findings.

References

Glenisson M, Salloum C, Lim C, Lacaze L, Malek A, Enriquez A, et al. Accessory liver lobes: anatomical description and clinical implications. J Visc Surg. 2014;151(6):451-5.

Brandtner MG, Stundner-Ladenhauf HN, Lapointe-Rohde S, Schimke C, Kluth D, Metzger R. Pediculated Accessory Liver Lobe with Gallbladder in a Preterm with Umbilical Cord Hernia. Children (Basel). 2022;9(11):1.

Thakral CL, Shivalingam G, Dar FM, Thakral N. Torsion of an Accessory Hepatic Lobe with Embedded Gallbladder: In an 11-Month-Old Boy. European J Pediatr Surg Rep. 2017;5(1):e62-e4.

Tarditti FD, Torres MB, Yazigi NA, Rumbo C, Zandieh AR, Gondolesi GE. Pedunculated Accessory Liver Lobe Containing the Gallbladder Presenting as Biliary Obstruction: A Case Report. Cureus. 2025;17(7):e88182.

Nagano A, Onishi S, Kedoin C, Matsui M, Murakami M, Sugita K, et al. A rare case of accessory liver lobe torsion in a pediatric patient who showed recurrent epigastralgia and who was treated by elective laparoscopic resection. Surg Case Rep. 2021;7(1):143.

Elmasalme F, Aljudaibi A, Matbouly S, Hejazi N, Zuberi MS. Torsion of an accessory lobe of the liver in an infant. J Pediatr Surg. 1995;30(9):1348-50.

Ito F, Ando H, Watanabe Y, Seo T, Murahashi O, Harada T, et al. An accessory lobe of the liver disturbing closure of the umbilical ring. Pediatr Surg Int. 1999;15(5-6):394-6.

Koplewitz BZ, Manson DE, Ein SH. Posttraumatic torsion of accessory lobe of the liver and the gallbladder. Pediatr Radiol. 1999;29(11):799-802.

Umehara M, Sugai M, Kudo D, Hakamada K, Sasaki M, Munakata H. Torsion of an accessory lobe of the liver in a child: report of a case. Surg Today. 2009;39(1):80-2.

Sangüesa C, Esteban MJ, Gomez J, Cotina H. Liver accessory lobe torsion in the infant. Pediatr Radiol. 1995;25(2):153-4.

Xiong X, Lou Y, Zhou T, Zheng Z, Liu Y, Liu R, et al. Case report: A case of giant accessory hepatic lobe torsion combined with left hepatic vein branch thrombosis in a child. Front Pediatr. 2022;10:970876.

Chaussy Y, Manzoni P, Ridley A, Auber F. An Unusual Cause of Abdominal Pain. J Pediatr. 2018;195:303-e1.

Koumanidou C, Nasi E, Koutrouveli E, Theophanopoulou M, Hilari S, Kakavakis K, et al. Torsion of an accessory hepatic lobe in a child: ultrasound, computed tomographic, and magnetic resonance imaging findings. Pediatr Surg Int. 1998;13(7):526-7.

Calame P, Lenoir M, Delabrousse E. Imaging features of accessory liver lobe torsion. Diagn Interv Imaging. 2021;102(1):59-60.

Pérez-Martínez A, Conde-Cortés J, Martínez-Bermejo MA, Bento-Bravo L. Torsion of a pedunculated accessory hepatic lobe: differential diagnosis of projectile vomiting in a neonate. J Perinat Med. 2006;34(3):248-9.

Badlis M, Amari K, Alkheshi M, Alolaby K, Alsaid B. Ultrasound and computed tomography in differentiating between simple and complicated appendicitis in pediatric patients. Pediatr Surg Int. 2024;40(1):299.

Ladurner R, Brandacher G, Mark W, Iannetti C, Lottersberger C, Steurer W, et al. Complete hepatic ischemia due to torsion of a large accessory liver lobe: first case to require transplantation. Transpl Int. 2005;18(4):467-9.