Incidental Detection of Post-cholecystectomy Lemmel Syndrome With Burr Hole Plating and Ventriculoperitoneal Shunt: A Cadaveric Case Report of Quadruple Pathology and Clinico-Pathophysiological Correlation

During surgical anatomy dissection on a cadaveric subject for educational purposes in a medical university, we encountered a rare syndrome and evidence of a constellation of three past surgeries, which provided us with an intellectually rewarding tapestry of clinical and academic findings sufficient to enrich the overall learning experience. During her lifetime, the elderly female subject had undergone a cholecystectomy, presumably for calculous cholecystitis. The dissection also revealed what was putatively diagnosed as type III Lemmel syndrome, characterized by a large periampullary duodenal diverticulum and dilated common bile duct, apart from a smaller duodenal diverticulum near the duodenojejunal flexure. She had a ventriculoperitoneal (VP) shunt implanted from the occipital horn of the right ventricle to the right hypochondrial peritoneal cavity. Finally, she had a right parietal skull burr hole covered with a titanium cranial implant after the evacuation of a possible subdural hematoma during her lifetime. No description could be found in the cadaveric dissection literature with this constellation of findings in one subject. There is a significant relationship between duodenal diverticula and gallstone disease, especially choledocholithiasis. The possible interplay between the two intracranial findings is complex and can be bidirectional, which are discussed in this case report. There is no known clinico-pathophysiological relationship between biliary tract and duodenal findings, on the one hand, and the intracranial observations, on the other. However, a possible association between intra-abdominal pathology and VP shunt malfunction has been postulated. This case report is also an expression of the law of unintended consequences with positive effects. What was supposed to be a routine cadaveric dissection for anatomical studies turned out to be a veritable clinico-pathophysiological discourse. Instead of merely restricting our medical teaching to normal anatomical findings in cadaveric dissections, we adopted an open-minded approach to enrich the learning experience for not only entry-level medical students but also higher-level medicos and even surgical residents. This opened up hitherto overlooked pathophysiological vistas that enabled us to exercise our clinico-pathophysiological acumen, as is demonstrated in this case report.