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WeBSurg, the e-surgical reference of Laparoscopic surgery

Clinical Case

RIGHT HEPATIC DUCT ANOMALY


B Malassagne, MD , Hôpital Henri Mondor, Paris, France
B Poupard, MD , Polyclinique La Pergola, Vichy, France

1. Description


CBD injury during laparoscopic cholecystectomy can be due to several factors. One such factor is the unrecognized presence of biliary tree anomalies. This case illustrates the risk of right hepatic duct injury due to an anatomical variation of the biliary tree. The risk was recognized with intraoperative cholangiography and immediately managed intraoperatively.

2. Keywords


Biliary tree anomaly, right hepatic duct injury, bile duct injury

3. Patient


64-year-old female

4. Past medical history


- hypertension;
- appendectomy;
- hysterectomy.

5. History of present illness


The patient presents with a gradual onset of painless jaundice. She denies fever or abdominal pain. There is no previous history of biliary pathology.

6. Physical examination


The patient is jaundiced.
She displays a soft right upper quadrant with no tenderness. The gallbladder is not palpable. There is no suspicious adenopathy or ascites.

7. Laboratory workup


- AST: 55 UI/l (9-38);
- ALT: 64 UI/l (12-50);
- bilirubin: 112 mmol/l (3.4-20.5);
- direct bili: 82 mmol/l (1.7-6.8);
- amylase, lipase: normal.

8. ERCP


The patient undergoes an ERCP that successfully removes multiple stones from the biliary tree. A sphincterotomy is performed.

9. Clinical progression


The patient's post ERCP course is uneventful and a laparoscopic cholecystectomy is planned.

10. Ultrasonography


Atrophic gallbladder with wall thickening consistent with chronic cholecystitis.
Dilated intrahepatic and extrahepatic biliary tree.

11. ERCP


The patient undergoes an ERCP that successfully removes multiple stones from the biliary tree. A sphincterotomy is performed.

12. Clinical progression


The patient's post-ERCP course is uneventful and a laparoscopic cholecystectomy is planned.

13. Operative findings


Thickened inflamed gallbladder with the inflammatory process extending to the hilar area. Because of this inflammation, the gallbladder is dissected in an antegrade manner. The cystic duct is thus identified as the only duct exiting the gallbladder. An intraoperative cholangiogram is performed.

14. Cholangiography


The cholangiography demonstrates the absence of a cystic duct with direct insertion of the gallbladder into the right hepatic duct. A large stone is impacted at the papilla of Vater with no outflow to the duodenum.

15. Operative findings


The decision to convert to a laparotomy is taken. The impacted stone is removed via the opening in the right hepatic duct and the duct is repaired over a T-tube.

16. Clinical progression


The patient has an uneventful postoperative course.

17. Discussion


This case illustrates several important aspects of the management of unsuspected anomalies of the biliary tree. The laparoscopic exploration had revealed evidence of acute cholecystitis with inflammation extending down to the hilar area. This is a well known risk factor for biliary tract injuries (BTI). Kum et al. in 1996 reported an increased incidence (from 0.2% to 5.5%) of BTI in the setting of acute cholecystitis. The decision to convert made by the surgeon in this case is wise and should not be looked upon as a failure.
The second point to be made here is to emphasize the importance of intraoperative cholangiography (IOC) when the surgeon is faced with unexpected biliary tree anatomic variations. While the impact of routine cholangiography on the reduction of BTIs is debatable, in situations where doubts about the anatomical structures exist, such as this case, IOC may delineate the anatomical landmarks and result in a reduction of the severity of the BTI due to early recognition (before the CBD is transected for example). Furthermore, IOC allows proper identification of the biliary tract variations or anomalies for proper management.
This case illustrates one of the most dangerous anomalies of the hepatic ducts. While biliary anatomical variations are encountered in 18-39% of cases, hazardous anomalies predisposing to BTI are present in only 3-6% of such cases. The variation illustrated here is one of a low biliary convergence with a direct insertion of the cystic duct into the right hepatic duct.

18. References


  1. Asbun HJ, Rossi RL, Lowell JA, Munson JL. Bile duct injury during laparoscopic cholecystectomy: mechanism of injury, prevention, and management. World J Surg 1993;4:547-51.
  2. Bismuth H, Lazorthes F. 83rd Congress of the French Surgical Society (Paris, 21-24 September 1981). Second report. Operative injuries of the common biliary duct. J Chir 1981;10:601-9.
  3. Fletcher DR, Hobbs MS, Tan P, Valinsky LJ, Hockey RL, Pikora TJ et al. Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population-based study. Ann Surg 1999;4:449-57.
  4. Kum CK, Chua TE. Management of acute cholecystitis in the era of laparoscopic surgery. Ann Acad Med Singapore 1996;5:640-2.
  5. Stewart L, Way LW. Bile duct injuries during laparoscopic cholecystectomy. Factors that influence the results of treatment. Arch Surg 1995;10:1123-8.
  6. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;1:101-25.
  7. Woods MS, Traverso LW, Kozarek RA, Donohue JH, Fletcher DR, Hunter JG et al. Biliary tract complications of laparoscopic cholecystectomy are detected more frequently with routine intraoperative cholangiography. Surg Endosc 1995;10:1076-80.