The presence of aberrant bile ducts is a significant risk factor for bile duct injuries during cholecystectomy. Identification of such anatomic anomalies of the biliary tree is crucial to prevent iatrogenic biliary injuries. For that purpose many methods, both preoperative and intraoperative, have been described with controversial results. We present a case of an aberrant right hepatic duct that was found during laparoscopic cholecystectomy with the use of intraoperative cholangiography and review the literature

Atmatzidis, Konstantinos

Atmatzidis, Stefanos

Chatzimavroudis, Grigoris

Koutelidakis, Ioannis

Makris, John

Papaziogas, Basilis

Psaralexis, Konstantinos

English

Aristotle University of Thessaloniki: Open Journals / ΑΡΙΣΤΟΤΕΛΕΙΟ ΠΑΝΕΠΙΣΤΗΜΙΟ ΘΕΣΣΑΛΟΝΙΚΗΣ

	 Uncomplicated	Intraoperative	Evaluation	of	an	Aberrant	Bile	Duct	 53INTRODUCTIONImprovement	 in	 radiologic	 imaging	 methods	 has	shown	 that	 the	 incidence	 of	 abnormal	 biliary	 tree	anatomy	is	not	as	uncommon	as	previously	thought,	ranging	from	1.4%	to	27%1.	The	presence	of	aberrant	bile	duct(s)	is	responsible	for	a	significant	proportion	of	extrahepatic	biliary	tree	abnormalities	and	signifi-cantly	contributes	to	the	increased	risk	of	bile	duct	in-juries	during	cholecystectomy.	Identification	of	such	anomalies	 preoperatively	 and/or	 intraoperatively	 is	critical	in	order	to	eliminate	the	risk	of	iatrogenic	bili-ary	 injury,	which	 is	associated	with	substantial	mor-bidity	and	occasional	mortality.We	herein	report	a	case	of	an	aberrant	right	hepatic	duct	that	was	accidentally	discovered	intraoperatively	and	 discuss	 the	 clinical	 importance	 of	 verifying	 the	biliary	tree	anatomy	in	order	to	avoid	biliary	injury.CASE REPORTA	81-year	old	woman	was	admitted	to	our	department	for	surgical	management	of	symptomatic	cholelithia-sis.	The	patient’s	past	medical	history	included	repeat-ed	episodes	of	colic	pain	in	the	right	upper	quadrant,	as	 well	 as	 four	 episodes	 of	 cholecystitis	 during	 the	last	2	years.	The	preoperative	sonogram	of	the	upper	abdomen	showed	thickening	of	the	gallbladder’s	wall	and	 presence	 of	multiple	 gallstones	within	 the	 gall-bladder;	no	dilatation	of	the	intra-	or	extrahepatic	bile	ducts	was	noted.The	 patient	was	 planned	 for	 laparoscopic	 chole-cystectomy.	After	 the	 establishment	 of	 the	 pneumo-peritoneum,	the	gallbladder	was	noticed	to	be	covered	with	dense	adhesions	to	the	omentum	and	the	hepatic	flexure	 of	 the	 colon	 due	 to	 the	 preceding	 episodes	of	 cholecystitis.	 The	 adhesions	 were	 separated	 me-ticulously.	While	dissecting	cystohepatic	triangle	(of	Calot)	 and	 after	 identifying	 the	 cystic	 duct	 and	 the	common	 bile	 duct	 (CBD),	 a	 5-mm-in	 diameter	 tu-bular	structure	was	seen	which	paralled	the	common	hepatic	duct	and	seemed	to	drain	into	the	cystic	duct.	Due	to	inability	to	recognize	the	anatomical	structures	with	safety,	a	cholangiogram	through	the	cystic	duct	was	performed,	which	showed	the	presence	of	an	ab-errant	 right	 hepatic	 duct	 draining	 the	 segments	 VII	and	VIII	of	the	liver	and	entering	the	cystic	duct	just	5mm	above	the	entry	of	the	cystic	duct	into	the	com-mon	bile	duct.	(Figure	1)	The	cystic	duct	was	ligated	close	 to	 the	neck	of	 the	gallbladder,	 thus	preserving	the	 drainage	 of	 the	 aberrant	 bile	 duct	 into	 the	CBD	through	the	remnant	cystic	duct.	The	cholecystectomy	was	completed	without	any	further	problems.Case RepoRtUncomplicated intraoperative evaluation of an aberrant  bile duct: a case report and review of the literature.Grigoris	Chatzimavroudis,	Basilis	Papaziogas,	Ioannis	Koutelidakis,		Stefanos	Atmatzidis,	Konstantinos	Psaralexis,	John	Makris,	Konstantinos	Atmatzidis2nd Surgical Department, Medical School, Aristotle University of Thessaloniki, GreeceABSTRACT: The presence of aberrant bile ducts is a significant risk factor for bile duct injuries during cholecystectomy.	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Identification	of	such	anatomic	anomalies	of	the	biliary	tree	is	crucial	to	prevent	iatrogenic	biliary	injuries.	For	that	purpose	many	methods,	both	preoperative	and	intraoperative,	have	been	described	with	controversial	results.	We	present	a	case	of	an	aberrant	right	hepatic	duct	that	was	found	during	laparoscopic	cholecystectomy	with	the	use	of	intraoperative	cholangi-ography	and	review	the	literature.Key Words: Aberrant bile duct, Accessory hepatic duct, Intraoperative cholangiography, Cholecystectomy.Corresponding author: Grigoris Chat�imavroudis, MD, �hD, Kampouridou str. ��, ��2��, �anorama, Greece,          Tel.: +�0 2��0 80��02, Fax: +�0 2��0 ��2���, e�mail: gchat�im�med.auth.gr 54	 Aristotle	University	Medical	Journal,	Vol.	35,	Issue	2,	June	2008The	postoperative	course	was	uneventful	and	the	patient	was	discharged	from	the	hospital	in	3	days.DISCUSSIONThough	variations	of	the	biliary	tree	are not rare, the	 	 	 	exact	prevalence	of	abnormal	biliary	anatomy	is	wide-ly	ranging.	Especially,	the	prevalence	of	aberrant	bile	ducts	is	unknown	as	there	are	huge	differences	in	rates	among	both	 clinical	 studies	 (1.4-17%)2,3	 and	human	autopsy	 specimens	 (4-28%)4,5.	A	possible	 reason	 for	those	differences	is	the	controversy	regarding	the	use	of	terms	aberrant	and	accessory	bile	ducts.	Although	there	are	studies	that	use	those	terms	as	synonyms,	we	believe	the	term	aberrant	should	be	used	just	for	those	ducts	that	present	the	only	route	of	drainage	of	one	or	several	hepatic	segments6.The	development	of	aberrant	bile	ducts	is	thought	to	be	secondary	to	an	inhibition	of	primitive	intestinal	bud	or	an	abnormality	of	formation of primary hepatic	 	 	 	furrow	during	the	first	week	of	embryogenesis7. The	 	majority	of	aberrant	ducts	arises	 from	the	right	 lobe	of	the	liver	(more	than	95%	of	cases)	and	drains	into	the	common	hepatic	duct	in	more	than	70%	of	cases8.	In	our	case	the	aberrant	bile	duct	arose	from	the	right	lobe	of	the	liver	draining	the	segments	VII	and	VIII,	but	instead	of	the	common	hepatic	duct,	it	entered	the	cystic	duct,	 just	5	mm	above	its	entry	 into	 the	com-mon	bile	 duct.	According	 to	Hisatsugu,	 this	 type	of	aberrant	bile	duct	does	not	exceed	7%	of	all	cases	of	aberrant	or	accessory	bile	ducts9.Aberrant	bile	ducts	can	be	inadvertently	ligated	or	transected during cholecystectomy; the ligation of an	 	 	 	 	 	 	aberrant	bile	duct	leads	to	exclusion	of	bile	drainage	of	the	analog hepatic segment, thus causing elevation	 	 	 	 	 	of	 intrasegmental	 pressure	 and	 local	 biliary	 cirrho-sis	development;	transection	of	an	aberrant	bile	duct	causes	bile	leakage	and	creation	of	fistula,	-if	there	is	a	drainage	tube-,	biloma	or	biliary	peritonitis.	Both	situ-ations	(ligation	and	transection)	significantly	increase	morbidity	and	mortality	and	thus	need	to	be	avoided.	In	 order	 to	 eliminate	 the	 risk	 of	 bile	 duct	 injuries	 a	number	of	authors	propose	the	routine	performance	of	intraoperative	 cholangiography	 (IOP)	 during	 chole-cystectomy10-12.	However,	other	surgeons	believe	that	careful	dissection	of	Calot’s	triagle	and	exact	identi-fication	of	biliary	tree	anatomy,	especially	in	cases	of	acute	 inflammation,	having	always	 in	mind	 the	pos-sible	variations	of	both	biliary	tree	and	vascular	anat-omy,	are	appropriate	and	sufficient	measures	to	avoid	bile	 duct	 injuries13-15. Additionally,	 they	 emphasize	that	bile	duct	injuries	cannot	be	completely	prevented	by	routine	IOP.	However,	 they	mention	that	elective	IOP	should	always	be	performed	when	the	contents	of	Calot’s	triangle	cannot	be	recognised	safely.In	general,	IOP,	routine	or	selective,	is	a	feasible,	safe,	fast	and	accurate	method	for	detecting	bile	duct	anatomy;	only	minor	intraoperative	complications	of	less	than	1%	have	been	described,	with	no	further	con-sequences	for	the	patients11,16. However,	to	date	there	is	no	strong	evidence	of	the	efficacy	of	routine	IOP	in	preventing	bile	duct	injuries	and	as	a	consequence	its	use	versus	selective	IOP is	still	controversial.Instead	of	routine	IOP some	authors	propose	rou-tine	 preoperative	 evaluation	 of	 the	 anatomy	 of	 the	biliary	 tree	 by	 using	 radiologic	 imaging	 methods.	Taourel	et	al	evaluated	the	accuracy	of	magnetic	reso-nance	 cholangiopancreatography	 (MRCP)	 in	 the	 di-agnosis	 of	 anatomic	 variations	 of	 the	 biliary	 tree	 in	171	 patients	 and	 found	 that	MRCP	 leads	 accurately	and	 safely	 to	 identification	 of	 biliary	 tree	 anatomic	variants	that	may	increase	the	risk	of	bile	duct	injury	during	 laparoscopic	cholecystectomy17. On	the	other	Figure 1. Intraoperative	cholangiogram	showing	the	anat-omy	of	the	biliary	tree	and	the	presence	of	a	right	aberrant	bile	duct	entering	the	cystic	duct.	 Uncomplicated	Intraoperative	Evaluation	of	an	Aberrant	Bile	Duct	 55hand,	Hirao	et	al	compared	helical	CT	cholangiogra-phy	with	MRCP	and	found	that	helical	CT	cholangi-ography	is	superior	 to	MRCP	regarding	its	accuracy	in	detection	of	aberrant	or	accessory	bile	ducts18. The	efficacy	of	helical	CT	cholangiography	in	identifica-tion	 of	 biliary	 tree	 anatomy	 has	 been	 confirmed	 by	several	other	studies19,20;	however,	the	role	of	MRCP	is	still	important,	especially	in	cases	in	which	the	use	of	a	contrast	medium	is	contra-indicated,	choledocho-lithiasis	is	suspected,	a	cystic	duct	is	occluded,	or	both	the	bile	duct	and	the	pancreatic	duct	image	need	to	be	obtained	simultaneously21.	About	10	years	 ago	 laparoscopic	ultrasound	was	introduced	during	laparoscopic	cholecystectomy	as	a	newer	intraoperative	imaging	method	which	proved	to	be	effective	in	detecting	bile	duct	stones	and	evaluat-ing	biliary	anatomy	in	many	studies22-23. The	main	ad-vantages	of	laparoscopic	ultrasound	over	IOC	include	speed	 in	completing	 the	examination,	 safety,	 repeat-ability,	more	imaging	information	and	lower	cost.	The	disadvantages	 include	 examiner	 dependency,	 steep	learning	curve,	need	for	special	equipment	and	certain	limitations	in	imaging	capability.	According	to	Machi	et	 al	 the	use	of	 IOC	 is	 indicated	when	 laparoscopic	ultrasound	is	not	complete	or	satisfactory	in	screening	the	bile	duct	for	stones	or	in	providing	clear	anatom-ic	 information	 for	 safe	 performance	 of	 laparoscopic	cholecystectomy.	When	aberrant	anatomy	or	bile	duct	anomalies	are	suspected,	or	when	bile	duct	injuries	are	a	concern,	IOC	should	be	performed24.	In	 conclusion,	 the	 presence	 of	 anatomic	 variants	of	biliary	tree,	including	aberrant	bile	ducts,	is	a	sig-nificant	risk	factor	for	bile	duct	injuries	and	accurate	evaluation	of	the	anatomy	of	biliary	tree	is	considered	essential	 to	 perform	 cholecystectomy	 with	 safety.	For	 the	evaluation	of	 the	biliary	 tree	anatomy	many	methods	 have	 been	 described,	 including	 routine	 or	selective	IOC,	laparoscopic	ultrasound	and	preopera-tive	MRCP	or	CT	cholangiography.	However,	none	of	these	methods	can	eliminate	bile	duct	injuries	unless	there	 is	 essential	 knowledge	 of	 normal	 biliary	 tree	anatomy	 and	 its	 variations	 and	 appropriate	 surgical	technique	is	applied.	ΠΕΡΙΛΗΨΗ:	Η	ύπαρξη	έκτοπων	χολαγγείων	αυξάνει	σημαντικά	τον	κίνδυνο	διεγχειρητικής	κάκωσης	των	εξωηπατικών	χοληφόρων	στη	διάρκεια	της	χολοκυστεκτομής.	Η	αναγνώριση	τέτοιων	ανατομικών	παραλλαγών	του	χοληφόρου	δέντρου	έχει	ιδιαίτερη	σημασία	στην	πρόληψη	ιατρογενών	κακώσεων	αυτού.	Για	το	σκοπό	αυτό,	ποικίλες	μέθοδοι,	τόσο	προεγχει-ρητικές	όσο	και	διεγχειρητικές,	έχουν	περιγραφεί,	με	διφορούμενα	όμως	αποτελέσματα.	Παρουσιάζουμε	ασθενή	με	έκτοπο	δεξιό	ηπατικό	πόρο,	ο	οποίος	αναγνωρίστηκε	στη	διάρκεια	λαπαροσκοπικής	χολοκυστεκτομής	με	τη	χρήση	διεγχειρητικής	χολαγγειογραφίας	και	ανασκοπούμε	τη	διεθνή	βιβλιογραφία.Λέξεις Κλειδιά: Έκτοπο χολαγγείο, Επικουρικό χολαγγείο, Διεγχειρητική χολαγγειογραφία, Χολοκυστεκτομή.Ανεπίπλεκτη διεγχειρητική αναγνώριση έκτοπου χολαγγείου:  παρουσίαση περιστατικού και ανασκόπηση της βιβλιογραφίας.Γρηγόριος	Χατζημαυρουδής,	Βασίλειος	Παπαζιώγας,	Ιωάννης	Κουτελιδάκης,		Στέφανος	Ατματζίδης,	Κωνσταντίνος	Ψαραλέξης,	Ιωάννης	Μακρής,	Κωνσταντίνος	ΑτματζίδηςΒ΄ Χειρουργική Κλινική, Ιατρική Σχολή, Αριστοτέλειο Πανεπιστήμιο Θεσσαλονίκης56	 Aristotle	University	Medical	Journal,	Vol.	35,	Issue	2,	June	2008		1. Uchiyama K, Tani M, Kawai M, Ueno M, Hama T,	 	 	 	 	 	 	 	 	 	 	Yamaue	H.	Preoperative	evaluation	of the extrahepatic	 	 	bile	duct	 structure	 for	 laparoscopic	cholecystectomy.	Surg	Endosc	2006;20:1119-1123.		2.	 Jamshidi	 M,	 Obermeyer	 RJ,	 Garcia	 G,	 Hashmi	 M.	Postlaparoscopic	 cholecystectomy	 bile	 leak	 second-ary	 to	 an	accessory	duct	of	Luschka.	 Int	Surg	1999;	84:86-88.		3.	 Suhocki	 PV,	 Meyers	 WC.	 Injury	 to	 aberrant	 bile	ducts	during	cholecystectomy:	a	common	cause	of	di-agnostic	 error	 and	 treatment	 delay.	A	 J	R	 1999;172:	955-959.		4.	 Knight	M.	Anomalies	of	the	gallbladder	bile	ducts	and	arteries.	 In:	Lord	Smith	of	Marlow,	Sherlock	S,	 edi-tors.	Surgery	of	the	gallbladder	and	bile	ducts.	2nd	ed.	Oxford:	Butterworth-Heinemann	1981,	p.	97-116.		5.	 Williams	C,	Williams	AM.	Abnormalities	of	 the	bile	ducts.	Ann	Surg	1955;141:598-613.		6.	 Papaziogas	B,	Paraskevas	G.	Congenital	anomalies	of	the	extrahepatic	biliary	tree.	University	Studio	Press,	Thessaloniki,	2006.		7.	 Boyden	EA.	The	problem	of	 the	double	ductus	cho-ledochus	 (an	 interpretation	of	an	accessory	bile	duct	found	attached	to	the	pars	superior	of	the	duodenum).	Anat	Rec	1932;55:71-93.		8.	 Moosman	D,	Coller	F.	Prevention	of	traumatic	injury	to	the	bile	ducts.	Am	J	Surg	1951;82:132-143.		9.	 Hisatsugu	T.	Extrahepatic	 bile	 duct	 abnormality	 and	surgery.	 In:	Hisatsugu	T	 (ed).	Extrahepatic	 bile	 duct	abnormality	 and	 surgery.	 Daidohgakkann,	 Fukuoka	1994,	27-102.10.	 Waage	A,	Nilsson	M.	 Iatrogenic	Bile	Duct	 Injury:	A	population-based	study	of	152	776	cholecystectomies	Arch Surg. 2006;	141:	1207-1213.11.	 Nickkholgh	 A,	 Soltaniyekta	 S,	 Kalbasi	 H.	 Routine	versus	 selective	 intraoperative	 cholangiography	 dur-ing	 laparoscopic	cholecystectomy:	a	survey	of	2,130	patients	 undergoing	 laparoscopic	 cholecystectomy.	Surg	Endosc	2006;20:868-874.12.	 Debru	E,	Dawson	A,	Leibman	S,	Richardson	M,	Glen	L,	Hollinshead	J,	Falk	GL.	Does	routine	intraoperative	cholangiography	 prevent	 bile	 duct	 transection?	 Surg	Endosc	2005;19:589-593.13.	 Ucchedu	A,	Pisanu	A,	Cois	A,	Cillara	N.	Can	 intra-operative	cholangiography	be	avoided	during	laparo-scopic	cholecystectomy?	Chir	Ital	2005;57:571-7.14.	 Lorimer	 JW.	Results	of	 cholecystectomy	without	 in-traoperative	 cholangiography.	 Can	 J	 Surg	 2004;47:	343-346.15.	 Metcalfe	MS,	Ong	T,	Bruening	MH,	Iswariah	H,	We-myss-Holden	SA,	Maddern	GJ.	Is	laparoscopic	intra-operative	 cholangiogram	 a	 matter	 of	 routine?	Am	 J	Surg	2004;187:475-481.16.	 Morgan	 S,	 Traverso	 LW.	 Intraoperative	 cholangiog-raphy	 and	 postoperative	 pancreatitis.	 Surg	 Endosc	2000;14:264-266.17.	 Taourel	 P,	 Bret	 PM,	 Reinhold	 C,	 Barkun	 AN,	 Atri	M.	 Anatomic	 variants	 of	 the	 biliary	 tree:	 diagno-sis	 with	 MR	 cholangiopancreatography.	 Radiology	1996;199:521-527.18.	 Hirao	K,	Miyazaki	A,	Fujimoto	T,	Isomoto	I,	Hayashi	K.	 Evaluation	 of	 aberrant	 bile	 ducts	 before	 laparo-scopic	 cholecystectomy:	 helical	 CT	 cholangiogra-phy	 versus	 MR	 cholangiography.	Am	 J	 Roentgenol	2000;175:713-720.19.	 Fleischmann	D,	Ringl	H,	Schofl	R,	Potzi	R,	Kontrus	M,	Henk	C,	Bankier	AA,	Kettenbach	J,	Mostbeck	GH.	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Routine	 laparoscopic	 ultrasound	 can	significantly	reduce	the	need	for	selective	intraopera-tive	 cholangiography	 during	 cholecystectomy.	 Surg	Endosc	2007;21:270-274.REFERENCES

Uncomplicated intraoperative evaluation of an aberrant bile duct: a case report and review of the literature

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Uncomplicated intraoperative evaluation of an aberrant bile duct: a case report and review of the literature

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Aristotle University of Thessaloniki: Open Journals / ΑΡΙΣΤΟΤΕΛΕΙΟ ΠΑΝΕΠΙΣΤΗΜΙΟ ΘΕΣΣΑΛΟΝΙΚΗΣ