traumatic gallbladder rupture occurs rarely and the incidence is reported to amount to approximately 2% of all blunt abdominal injuries .
the main reason for the low incidence is that the gallbladder is protected by the surrounding organs , including the liver , intestines , omentum , and ribs .
preoperative diagnosis of gallbladder rupture is generally difficult because no specific symptoms are observed and other concomitant organ injuries are common .
gallbladder rupture is usually diagnosed at laparotomy because emergency operation is necessary due to other organ injuries . however , even in the isolated gallbladder rupture which does not need an emergency operation , prompt diagnosis of gallbladder rupture is quite challenging due to the lack of specific symptoms .
it is very difficult to detect a defect in the gallbladder wall even when using imaging such as ultrasonography , computed tomography ( ct ) , and magnetic resonance imaging ( mri ) .
however , such images can detect the accumulation of intraperitoneal fluid including hemorrhage and bile .
if accumulated fluids contain bile , endoscopic cholangiography is useful not only to diagnose the gallbladder injury but also to determine the therapeutic strategy .
we present the details of a patient who underwent laparoscopic cholecystectomy after an exact preoperative diagnosis of traumatic gallbladder rupture .
a 43-year - old man fell off a tractor and was subsequently run over by the tractor . on admission to our emergency department , his vital signs were stable and he was alert .
complete blood count revealed a white blood cell count of 21,800/mm and a hemoglobin level of 14.0 g / dl .
enhanced abdominal ct suggested a mild liver laceration in hepatic segment 5 and a small amount of hemorrhagic ascites around the liver ( fig .
the tentative diagnosis was liver injury with edward 's classification grade i , and conservative treatment was initiated .
the day after admission , the right upper quadrant pain and ascites increased and a muscular defense sign appeared .
percutaneous drainage of the ascites was performed , and the aspirated fluid was bloody and almost pure bile . although his abdominal pain improved after continuous drainage , the amount of biliary discharge reached 800 ml / day .
mri and ultrasonography revealed little about the source of the bile leakage ; therefore , on the 10th day after abdominal blunt injury , endoscopic retrograde cholangiography was performed , and a diagnosis of gallbladder rupture was made ( fig .
2 ) . laparoscopic cholecystectomy was subsequently performed and revealed biliary ascites accumulated in the upper right abdomen with the gallbladder covered by edematous greater omentum .
there were no injuries in other abdominal organs and no obvious injury in segment 5 of the liver .
after isolating the gallbladder , a perforation was seen in the gallbladder body , as suggested by endoscopic retrograde cholangiography ( fig .
the perforation in the gallbladder wall was sutured closed , and then standard cholecystectomy was performed .
blunt traumatic gallbladder injury is rare , and the most common causes are accidents associated with motor vehicles , falls , blows , kicks , or industrial work .
blunt gallbladder injury is classified into three types : contusion , avulsion , and laceration ( rupture or perforation ) , and lacerations are the most common after blunt injury .
the gallbladder injury in our case was categorized as a laceration with an exact preoperative diagnosis .
ct scan is the most useful examination when diagnosing abdominal injuries , and avulsion gallbladder injuries can easily be diagnosed by ct because the gallbladder is torn from the liver and hemorrhage is obvious .
however , no specific signs are revealed on ct for laceration gallbladder injuries . despite the substantial leakage of bile into the peritoneal cavity in our case
, we could not determine whether it was caused by a gallbladder injury or liver laceration , and further examinations and treatments were required because of the persistent high - volume bile leakage . as magnetic resonance cholangiopancreatography revealed little about the origin of the bile leakage ,
endoscopic retrograde cholangiopancreatography was planned . because gallbladder rupture is often associated with multiple organ injuries leading to peritonitis
, laparotomy is recommended as soon as possible after the diagnosis . however , ruptured gallbladder alone has no associated hemodynamic disorders after successful abdominal drainage ; therefore , emergent laparotomy is not required , and patients are good candidates for laparoscopic surgery .
also , the final diagnosis of gallbladder rupture can be confirmed laparoscopically and simultaneous minimally invasive treatment can then be performed . in conclusion ,
management of gallbladder injuries varies with the presence of other concomitant organ injuries and the degree and type of gallbladder injury . in cases with gallbladder rupture simply diagnosed by direct cholangiography ,
 abstractgallbladder rupture due to blunt abdominal injury is rare . 
 there are few reports of traumatic gallbladder injury , and it is commonly associated with other concomitant visceral injuries . 
 therefore , it is difficult to diagnose traumatic gallbladder rupture preoperatively when it is caused by blunt abdominal injury . 
 we report a patient who underwent laparoscopic cholecystectomy after an exact preoperative diagnosis of traumatic gallbladder rupture . 
 a 43-year - old man was admitted to our hospital due to blunt abdominal trauma . the day after admission , abdominal pain and ascites increased and a muscular defense sign appeared . 
 percutaneous drainage of the ascites was performed , and the aspirated fluid was bloody and almost pure bile . 
 he was diagnosed with gallbladder rupture by the cholangiography using the endoscopic retrograde cholangiopancreatography technique . 
 laparoscopic cholecystectomy was performed safely , and he promptly recovered . if accumulated fluids contain bile , endoscopic cholangiography is useful not only to diagnose gallbladder injury but also to determine the therapeutic strategy . 