Biliary tract in trident, an anatomical variation between the cystic duct and its union to the common hepatic duct: a rare case report / Tracto biliar en tridente, una variación anatómica entre el conducto cístico y su unión al conducto hepático común: un caso raro

SUMMARY: Given that the gallbladder and the biliary tract are subject to multiple anatomical variants, detailed knowledge of embryology and its anatomical variants is essential for the recognition of the surgical field when the gallbladder is removed laparoscopically or by laparotomy, even when radiology procedures are performed. During a necropsy procedure, when performing the dissection of the bile duct is a rare anatomical variant of the bile duct, in this case the cystic duct joins at the confluence of the right and left hepatic ducts giving an appearance of trident. This rare anatomical variant in the formation of common bile duct is found during the exploration of the bile duct during a necropsy procedure, it is clear that the wrong ligation of a common hepatic duct can cause a great morbi-mortality in the postsurgical of biliary surgery. This rare anatomical variant not previously described is put in consideration to the scientific community. Anatomical variants of the biliary tract are associated with high rates of morbidity and mortality, causing serious bile duct injuries. Only the surgical skill of the surgeon and his open mind to the possibilities of abnormalities make the performance of cholecystectomy a safe procedure.

RESUMEN: Dado que la vesícula biliar y el tracto biliar están sujetos a múltiples variantes anatómicas, el conocimiento detallado de la embriología y sus variantes anatómicas es esencial para el reconocimiento del campo quirúrgico cuando la vesícula biliar se extirpa laparoscópicamente o por laparotomía, incluso cuando se realizan procedimientos de radiología. Durante un procedimiento de necropsia, se realiza la disección del conducto biliar y se observa una variante anatómica inusual del conducto biliar; en este caso, el conducto cístico se une a la confluencia de los conductos hepáticos derecho e izquierdo dando una apariencia de tridente. Esta rara variante anatómica en la formación del conducto biliar común puede causar una gran morbimortalidad en la cirugía biliar asociado a una ligadura incorrecta. Esta extraña variante anatómica no descrita anteriormente se reporta a la comunidad científica, debido a que las variantes anatómicas del tracto biliar se asocian con altas tasas de morbilidad y mortalidad, al causar lesiones graves en el conducto biliar. Solo la habilidad quirúrgica del cirujano y su mente abierta a las posibilidades de variaciones anatómicas hacen que la realización de la colecistectomía sea un procedimiento seguro.

Trígono cistohepático: área crítica anatómica para la seguridad quirúrgica / Trigonum cystohepaticum: critical anatomical area for surgical safety

El conocimiento de la anatomía de la vía biliar y sus variantes para la realización de una cirugía segura, resulta fundamental. La extirpación de la vesícula requiere cuidadosa atención, conocer muy bien la anatomía de la región, teniendo en cuenta la posibilidad de variaciones anatómicas. La mala interpretación de la anatomía percibida más que una falta en la destreza técnica es la causa de la lesión de la vía biliar durante la colecistectomía. Diferenciar el límite y el contenido del trígono cistohepático. Diseñar las áreas de Visión Crítica y de Seguridad como medida de seguridad en el paciente quirúrgico. Revisión de 458 partes quirúrgicos de colecistectomías de enero/2010 a octubre/2012, en el Servicio de Cirugía General del Hospital Aeronáutico Central, y disección de 12 cadáveres adultos formolizados al 10% en la III Cátedra de Anatomía - Facultad de Medicina - Universidad de Buenos Aires. De 458 colecistectomías, se clasificaron los partes quirúrgicos, dividiéndose según menciona: triángulo de Calot en 247 (53,93%); triángulo hepatocístico en 59 (12,88%); área de visión crítica en 152 (33,18%); ninguno mencionó al triángulo de Budde o trígono cistohepático. Se disecaron 12 cadáveres adultos donde se identificó: arteria cística originándose de arteria hepática derecha en 9 (75%); originándose de arteria hepática izquierda en 2 (16,66%) y originándose de arteria hepática en 1 (8,34%). En 7 (58,35%) se la visualiza en trígono cistohepático. El conocimiento de la anatomía de la vía biliar y sus variantes para la realización de una cirugía segura, resulta fundamental. El triángulo descrito por Calot corresponde a la mitad inferior del triángulo descrito por Buddé. El sector lateral (Triangulo de Seguridad) es el verdadero área de visión critica a disecar por la menor probabilidad de lesionar estructuras nobles.

Knowing the anatomy of the bile duct and its anatomical variations becomes essential to safely perform any surgery. Gallbladder resection requires careful attention: knowing the region's anatomy by heart and taking into account the possibility of anatomical variations. Misunderstanding the anatomy is not only a failure in technical ability but also a cause of injury to the bile duct during a cholescystectomy. The objectives of this study were, to distinguish the boundaries and content of the trigonum cystohepaticum. Furthermore, to design the areas of Safety and Critical Vision as a safety measure for the patient undergoing surgery. Analysis of 458 surgical reports on cholecystectomies performed from January 2010 to October 2012 by the Hospital Aeronáutico's General Surgery Department, and dissection of 12 adult cadavers preserved in a 10% formalin solution at the IIIrd Chair of Anatomy, School of Medicine, University of Buenos Aires. From 458 cholecystectomies, surgical reports were classified as mentioning: Calot triangle, 247 (53.93%); cystohepatic triangle, 59 (12.88%); critical vision area, 152 (33.18%). None of them mentioned Buddé triangle or trigonum cystohepaticum. Twelve adult cadavers were dissected in which we identified the cystic artery: originating from right hepatic artery, 9 (75%); originating from left hepatic artery, 2 (16.66%); and originating from hepatic artery, 1 (8.34%). Trigonum cystohepaticum is observed in 7 cadavers (58.35%). Knowing the anatomy of the bile duct and its anatomical variations becomes essential to safely perform any surgery. The triangle described by Calot is the lower half of the triangle described by Buddé. The lateral portion (Safety Triangle) is the area of critical vision to be dissected due to the lower probability of injuring noble structures.

Ductal variations in the Calot's triangle seen on laparoscopic cholecystectomy

To describe the frequency and pattern of ductal variations seen in the Calot's triangle on laparoscopic cholecystectomy. Descriptive study. This study was conducted in the Surgical Unit 1, Fauji Foundation Hospital, Rawalpindi from December 13, 20008 to February 22, 2011. 200 patients with a diagnosis of biliary colic, cholelithiasis, acute cholecystitis, empyema gall bladder and mucocele gall bladder were included in this study. Patients with age less than 15 years were excluded. Careful dissection of the Calot's triangle was carried out. The anatomical variations of the cystic duct and other anomalous variations in the region were noted and data analyzed on SPSS 10. The age range was 19 to 88 years with a mean of 48 years. The majority [88%] of the patients presented with a clinical diagnosis of biliary colic. The cystic duct was of normal size in 88%, short in 7%, and long in 5% of the cases. The cystic duct terminated laterally into the common hepatic duct in 94% of the cases, anteriorly into the common hepatic duct in 5% and posteriorly into the common hepatic duct in 1% of the cases. Each Calot's triangle differs from the other. Ductal variations are the hallmark of this region and their knowledge is mandatory for a safe laparoscopic cholecystectomy

Estudo anatômico das variações de posição da junção dos ductos cístico e hepático comum em fetos / Position variability anatomical study of the junction between cystic and common hepatic ducts in fetus

OBJETIVO: Definir e classificar as variações anatômicas da junção dos ductos cístico e hepático comum em fetos, analisando a freqüência, trajeto e relação entre eles. MÉTODOS: Dissecaram-se 33 fetos , no período de setembro de 1999 a julho de 2000, utilizando-se fotografias para registrar as junções cístico-hepáticas. As uniões foram classificadas como alta, média e baixa e, quanto ao curso, paralelo ou angular. Constatado o tipo de união, aferiu-se o comprimento dos ductos. RESULTADOS: Visualizou-se a junção cístico-hepática em 93,9 por cento dos fetos, sendo encontrada a inserção média em 45,2 por cento delas, a inserção alta em 29 por cento e a inserção baixa em 25,8 por cento. Quanto ao curso ductal, a união aguda foi observada em 71 por cento dos fetos, enquanto a paralela, em 29 por cento. Quanto ao comprimento ductal, o ducto cístico variou de 4 - 6 mm, o ducto hepático comum de 9 - 13 mm, e o ducto colédoco de 5 - 10 mm. CONCLUSÃO: Dentre as variações anatômicas, a inserção média foi a prevalente, seguida do curso angular, com comprimentos dos ductos cístico e hepático comum variando entre 6mm e 7 mm, respectivamente. Foi demonstrada uma freqüência significativa de inserção baixa cístico-hepático comum.

Laparoscopic anatomy of the patterns of union of cystic duct to the common hepatic duct

This study was carried out to determine the various patterns of union of cystic duct to the common bile duct and to find and document the most common patterns. Design: An observational study. Place and Duration of Study: Mayo and National Hospital, Lahore. Subjects and The study is based upon laparoscopic dissection of 600 patients done between December 1995 to December 2000. These dissections were carried out as a part of laparoscopic cholecystectomies performed on these patients. The pattern of union of cystic duct with the common hepatic duct was studied and anomalies documented. It was noted that the original pattern of the union on the right lateral side is seen only in 32% cases, whereas an overwhelming majority i.e. 68% does not follow the known anatomic patterns. The patterns seen in the study were grouped into three different types. It was evident from this study that the common pattern described by the text books does not represent the true picture and indeed a lot of variations exist in this area

effect of stone size on the frequency of biliary pain

This study was aimed at assessing the relationship between cystic duct and stone diameter with the frequency of biliary pain A prospective study of 30 patients admitted for cholecystectomy due to symptomatic cholelithiasis. The pattern of their frequency of pain was recorded since the first attack until admission and related to the diameters of their gallbladder stones and cystic ducts.Patients with a cystic duct diameter of 5 mm or less had more frequent attacks of pain per week than those with a diameter more than 5 mm [p = 0.0003]. The smaller the cystic duct diameter, the smaller the stone diameter [p<0.0001], and the smaller the stone the more frequent are the attacks of pain [p = 0.0001]. This study showed that there is a significant relationship between the frequency of biliary pain and the size of stone and the diameter of cystic duct. This observation may give a useful clue to surgeons in arranging priorities for operations

Video-coelioscopic anatomy of the cystic artery

Arterial bleeding is a serious problem in laparoscopic cholecystectomy, therefore careful identification of the cystic artery and its anomalies as seen through the video-laparoscope could be of significant help in avoiding one of the greatest problems of biliary surgery, namely iatrogenic injury of the bile ducts. So, we reviewed the anatomy of the cystic artery during 80 laparoscopic cholecystectomies. A normal cystic artery was found in [76.2%] of patients, doubling of the artery in [17.5%] and an artery inferior to the cystic duct in [6.2%]. Dissection of the porta is avoided until the lateral edge of the cystic duct is identified after that identification of the cystic artery is attempted. Cautery and sharp dissection of the tissues in the portal area should be done cautiously to identify any arterial anomalies

Role of cystic duct in gall stone disease clinico pathological correlation

Fifty cases with gall stone were included in this study 35 females and 15 males with mean age 46 years. The presence of gall stones was proved by ultrasonography and or cholecystography. All patients were investigated for liver functions, blood picture, blood sugar and serum creatinine before the operation. Exploration of common bile duct was done in 4 cases, cholesterol stone was found in 6 cases, pigment stones in 14 and remaining [30] with mixed [infected] stones. The cystic duct and gall bladder were examined grossly and histologically. The cystic duct was narrowed in 68% of cases and shared more or less the same inflammatory changes and its sequele as in the gall bladder associated with gall stones. Also, it is recommended to examine the cystic duct in any gall bladder specimen. The cystic duct plays an active role in the flow of bile into and out of the gall bladder.So its pathological changes may share in the pathogenosis of gall stones even in absence of inflammatory process in the gall bladder