Ann Hepatobiliary Pancreat Surg.  2020 May;24(2):221-227. 10.14701/ahbps.2020.24.2.221.

Isolated aberrant right cysticohepatic duct injury during laparoscopic cholecystectomy: Evaluation and treatment challenges of a severe postoperative complication associated with an extremely rare anatomical variant

• Vasiliadis K
• Moschou E
• Papaioannou S
• Tzitzis P
• Totsi A
• Dimou S
• Lazaridou
• Kapetanos
• Papavasiliou C

• KMID: 2500810
• DOI: http://doi.org/10.14701/ahbps.2020.24.2.221

Abstract

A typical bile duct branching patterns represent one of the major causes of bile duct injury (BDI) during laparoscopic cholecystectomy (LC). The most common classified variations of bile duct branching, involve the right posterior sectoral duct (RPSD) and its joining with the right anterior or left hepatic duct. Variant bile duct anatomy can rarely be extremely complex and unclassified. This report describes an extremely rare case of an isolated injury to an aberrant right hepatic duct formed by the joining of ducts from segments V, VII, and VIII draining into the cystic duct (cysticohepatic duct) during LC, associated with an inferior RPSD opening to left hepatic duct. Detailed evaluation of both endoscopic and magnetic cholangiograms established the diagnosis. Bile duct injury was subsequently managed surgically by a demanding Roux-en-Y hepaticojejunostomy. This extremely rare case aims to serve as a useful reminder of the consistent inconsistency of biliary anatomy, alerting surgeons to beware of variant bile duct branching patterns during open or LC that constitute a dreadful pitfall for severe and life-threatening bile duct injuries.

Keyword

Laparoscopic cholecystectomy; Bile duct injury; Right sectoral bile duct; Hepaticojejunostomy; Variability in bile duct branching pattern; Rule rather than the exception

Figure

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  Fig. 1 Magnetic resonance cholangiopancreatography depicting an isolated injury to an aberrant right hepatic duct with consequent right anterior section and superior segment of right posterior sector bile leak, combined with a right posterior inferior duct variation anomaly.

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  Fig. 2 Endoscopic retrograde cholangiography depicting normal findings apart from paucity of intrahepatic biliary filling, mainly in the right anterior liver section (area surrounded by a dotted line) providing indirect diagnostic signs of a possible sectoral duct injury.

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  Fig. 3 Intraoperative photograph. Identification and intubation of a bile leaking duct stump, measuring roughly 3 mm in diameter, located ∼0.5 cm antero-laterally to the clipped cystic duct stump (arrow).

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  Fig. 4 Schematic drawing of intrahepatic and extrahepatic biliary anatomy of the present case.

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  Fig. 5 Intraoperative cholangiogram through the stump of the injured duct (A) confirms complete transection of an anomalous right hepatic duct that filled segments V, VIII and VII of the right hemi-liver, and through the common bile duct (B) depicting no concomitant bile duct injuries.

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  Fig. 6 Intraoperative photograph. Following meticulous dissection and debridement of the aberrant cystico-hepatic duct stump, a 65-cm in length transmesocolic, retrogastric Roux-en-Y limb was anastomosed termino-laterally with the aberrant biliary duct stump over a 6-french transjejunal plastic tube.

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  Fig. 7 Cholangiogram obtained from the transanastomotic tube on the fifth postoperative day depicting normal anastomosis with complete opacification of segments V, VIII and VII of the liver without signs of leakage.

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  Fig. 8 Postoperative volume-rendered 3 Tesla MR cholangiopancreatography performed on the 20th POD depicting a normal anastomosis between the jejunal loop (yellow arrow) and the cystohepatic duct (white arrow).

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