Gallbladder agenesis (GA) is a rare embryological anomaly that presents acute cholecystitis like-symptoms. It is often an incidental finding diagnosed during surgery. We reported a case of GA in a patient who presented with dyspepsia and acute right upper abdomen pain with ultrasonographic signs of acute lithiasic cholecystitis. The preoperative assessment, according to first-level exams, is oriented to the diagnosis of acute lithiasic cholecystitis with atrophy and sclerosis. During laparoscopy, the proximal transverse colon was found strictly adherent to gallbladder fossa. The gallbladder was found to be absent. The surgical procedure consisted of lysis of multiple colo-hepatic adhesions. The diagnosis of congenital GA was made laparoscopically. The postoperative radiological images, based on CT and MR examinations, documented the diagnosis of GA with a biliary duct anatomical variant. The recovery was uneventful and the patient remained symptom-free for more than four years. GA is a clinical challenge that still poses diagnostic and therapeutic dilemmas. Although no diagnostic and therapeutic algorithm is accepted worldwide, due to heterogeneity of clinical scenarios and the variability in hospital facilities, surgeons have to be familiar with this rare entity, and conversion in laparotomy or unnecessary operative procedures should be avoided in the same operative setting.

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A 50-years old woman presented to the Emergency Department after 6 h of abdominal discomfort, pain, bowel distension, nausea and vomiting. She referred acute onset of oppressive pain in left upper quadrant and left flank with painful and tender abdomen. Bowel sounds were present. Rectal examination was unremarkable. Past medical history included hypertension and no previous abdominal surgery. Laboratory tests showed a slight increasing in white blood cell count (10.800/μL) and PCR (15 mg/dL). Computed tomography revealed a cluster of ileal or jejunal loops in the leftupper quadrant (lateral to the ligament of Treitz and posterior to the inferior mesenteric vein (IMV)) with dilated proximal small bowel loops (Fig. 1). The patient was placed in a slight anti-Trendelenburg position with a 10 right rotation. Three operative trocars were used. A laparoscopic exploration confirmed the diagnosis of a left paraduodenal hernia with about 130 cm of viable small bowel incarcerated. As well as adhesyolisis, gentle manoeuvres of traction and counter-traction with atraumatic graspers

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