# Laparoscopic Cholecystectomy in a Patient with Low-Lying Costal Arch due to Ankylosing Spondylitis: A Case Report

## TL;DR

A 53-year-old man with ankylosing spondylitis successfully underwent laparoscopic cholecystectomy despite anatomical challenges caused by his condition.

## Contribution

This case report highlights the successful use of the fundus-first technique in a rare clinical scenario involving AS.

## Key findings

- Laparoscopic cholecystectomy was safely performed in a patient with AS and a low-lying costal arch.
- The fundus-first approach facilitated dissection in a narrow surgical space caused by restricted rib mobility.
- No hemodynamic changes occurred during surgery despite increased intra-abdominal pressure.

## Abstract

Ankylosing spondylitis (AS) is a chronic inflammatory disease primarily affecting the sacroiliac joints and spine, which can lead to bony ankylosis during the healing process. The prevalence of AS in the Japanese population is relatively low, and encounters with such patients in routine clinical practice are uncommon.

The patient was a 53-year-old man with a history of AS under ongoing treatment. He had experienced epigastric discomfort and nausea for 1 month prior to presentation. Further examination suggested that his symptoms were caused by gallbladder stones, and laparoscopic cholecystectomy was performed. Intraoperative findings revealed restricted rib mobility and a low-lying costal arch due to AS, resulting in a very narrow working space in the upper abdomen. Since the dissection of Calot’s triangle was difficult, the fundus-first technique was employed to separate the gallbladder from the liver bed, followed by clipping and division of the cystic duct and cystic artery. No hemodynamic changes were observed in association with increased intra-abdominal pressure during surgery. The postoperative course was uneventful, and the patient was discharged on POD 3.

We report a case of laparoscopic cholecystectomy performed in a patient with AS, supplemented by a review of the literature.