An uncommon case of right hepatic duct entering cystic duct associated to multiple complications of biliary tract disease: acute pancreatitis, hepatolithiasis, acute cholecystitis and hepatic abscess.

Anatomical variations of the biliary tree pose diagnostic and treatment challenges. While most are harmless and often discovered incidentally during procedures, some can lead to clinical issues and biliary complications, making knowledge of these variants crucial to prevent surgical mishaps. Here, we present an unusual and clinically significant case. A 61-year-old man is admitted to the hospital with epigastric pain and diagnosis of pancreatitis of biliary origin and intermediate risk of choledocholithiasis. Magnetic resonance cholangiopancreatography (MRCP) reported hepatolithiasis and choledocholithiasis, whereas endoscopic retrograde cholangiopancreatography showed cystic drain of the right hepatic duct. One month later the patient presented again to the emergency room with increasing abdominal pain and a computed tomography that demonstrated the presence of hepatic abscess and acute cholecystitis. The patient underwent percutaneous drain abscess and a subtotal laparoscopic cholecystectomy. Biliary anatomical variants present challenges on the diagnostic investigations, interventional and surgical procedures, understanding the possible complications is essential.

Características anatómicas del conducto cístico en una muestra de cadáveres del anfiteatro de una institución universitaria en Bogotá (Colombia) / Anatomic Characteristics of the Cystic Duct in a Sample of Cadavers from the Amphitheater of a University Institution in Bogotá ­ Colombia / Características anatômicas do ducto cístico em uma amostra de cadáveres do anfiteatro de uma instituição universitária em Bogotá Colômbia

en comparación con otros países, en Colombia son escasos los estudios sobre las características anatómicas del conducto cístico. En este artículo se describen sus características anatómicas en una muestra de 60 especímenes cadavéricos de una institución universitaria de Bogotá. Materiales y métodos: se realizó un estudio descriptivo analítico transversal donde se empleó y disecó el conducto cístico de 60 bloques digestivos humanos. Resultados: siguiendo la clasificación de Taybi, se encontraron las variaciones: con implantación alta (75 %), baja (25 %), en espiral anterior (1.6 %), espiral posterior (1.6 %), conducto cístico accesorio (1.6 %) y doble conducto cístico (3.2 %). En cuanto a las dimensiones del conducto cístico, se evidenció una longitud promedio de 19.4 mm y un diámetro promedio de 3.3 mm. Las características anatómicas usuales fueron similares a las reportadas en la literatura. Conclusiones: la anatomía usual está presente en el 92 % de los casos, y las variantes anatómicas, en el 8 %. La longitud y el diámetro del conducto cístico están dentro del promedio reportado en la literatura.

Compared with other countries, few studies in Colombia have explored the anatomical characteristics of the cystic duct. In this study, the anatomical characteristics of the cystic duct were described in a sample of 60 cadaveric specimens from a university institution in Bogotá. Materials and methods: A cross-sectional analytical descriptive study was performed, in which the cystic duct of 60 human digestive blocks was used and dissected. Results: Based on the Taybi classification, the following variations of the cystic duct were found: high implantation (75%), low implantation (25%), anterior spi-ral (1.6%), posterior spiral (1.6%), accessory cystic duct (1.6%), and double cystic duct (3.2%). Regarding the dimensions of the cystic duct, an average length of 19.4 mm and an average diameter of 3.3 mm were evidenced. The usual anatomical characteristics were similar to those reported in the literature. Conclusions: The usual anatomy was present in 92% of cases and anatomical variants in 8%. The length and diameter of the cystic duct were within the average limits as reported in the literature.

em comparação com outros países, os estudos sobre as características anatômicas do ducto cístico são escassos na Colômbia. Neste estudo, as características anatômicas do ducto cístico são descritas em uma amostra de 60 espécimes cadavéricos de uma instituição universitária de Bogotá. Materiais e métodos: foi realizado um estudo descritivo analítico transversal onde foi utilizado e dissecado o ducto cístico de 60 blocos digestivos humanos. Resultados: seguindo a classificação de Taybi, foram encontradas as seguintes variações, com implantação alta (75%), implantação baixa (25%), espiral anterior (1.6%), espiral posterior (1.6%), ducto cístico acessório (1.6%) e cístico duto duplo (3.2%). Quanto às dimensões do ducto cístico, evidenciou-se comprimento médio de 19.4 mm e diâmetro médio de 3.3 mm. As carac-terísticas anatômicas usuais foram semelhantes às relatadas na literatura. Conclusões: a anatomia usual está presente em 92% dos casos e as variantes anatômicas em 8%. O comprimento e o diâmetro do ducto cístico estão dentro da média relatada na literatura.

Comparative evaluation of three laparoscopic cholecystectomy techniques in rabbit's model

Purpose: The aim of this randomized study was to compare the complications and perioperative outcome of three different techniques of laparoscopic cholecystectomy (LC). Changes in the liver function test after LC techniques were investigated. Also, we compared the degree of postoperative adhesions and histopathological changes of the liver bed. Methods: Thirty rabbits were divided into three groups: group A) Fundus-first technique by Hook dissecting instrument and Roeder Slipknot applied for cystic duct (CD) ligation; group B) conventional technique by Maryland dissecting forceps and electrothermal bipolar vessel sealing (EBVS) for CD seal; group C) conventional technique by EBVS for gallbladder (GB) dissection and CD seal. Results: Group A presented a longer GB dissection time than groups B and C. GB perforation and bleeding from tissues adjacent to GB were similar among tested groups. Gamma-glutamyl transferase and alkaline phosphatase levels increased (p ≤ 0.05) on day 3 postoperatively in group A. By the 15th postoperative day, the enzymes returned to the preoperative values. Transient elevation of hepatic transaminases occurred after LC in all groups. Group A had a higher adherence score than groups B and C and was associated with the least predictable technique. Conclusions: LC can be performed using different techniques, although the use of EBVS is highly recommended.

Resección laparoscópica de dilatación quística congénita del conducto cístico en un paciente pediátrico / Laparoscopic Resection of Congenital Cystic Dilatation of the Cystic Duct in a Pediatric Patient

Introducción: La dilatación quística congénita del conducto cístico o dilatación tipo VI de la clasificación de Todani, es una variante rara de dilatación congénita de la vía biliar. Objetivo: Explicar la metodología diagnóstica y terapéutica empleada en un caso pediátrico con esta entidad, y destacar la ventaja de su tratamiento oportuno por vía mínimamente invasiva. Presentación del caso: Paciente masculino de 6 años con sintomatología sugestiva de enfermedad vesicular, referido desde la atención secundaria por sospecha de quiste de colédoco. En el ultrasonido se detectaba una lesión ecolúcida adyacente a la vesícula biliar, sin dilatación de las vías biliares intrahepáticas. Se realizó colangiografía laparoscópica y se confirmó una dilatación quística aislada del conducto cístico, la cual se resecó por vía laparoscópica, igualmente. Conclusiones: La incidencia de la dilatación quística del conducto cístico es muy baja y se puede presentar en niños con sintomatología variable. El diagnóstico generalmente es tardío, puede sospecharse mediante la ecografía abdominal y confirmarse con la colangiografía laparoscópica, aun en ausencia de otros medios diagnósticos más modernos. Su reconocimiento y correcta clasificación permiten realizar el tratamiento quirúrgico definitivo exitosamente, de preferencia por vía laparoscópica(AU)

Introduction: Congenital cystic duct dilatation, or Todani classification type VI dilatation, is a rare variant of congenital bile duct dilatation. Objective: To explain the diagnostic and therapeutic methodology used in a pediatric case with this entity, and to highlight the advantage of its timely minimally invasive treatment. Case presentation: Six-year-old male patient with symptoms suggestive of gallbladder disease, referred from secondary care for suspicion of a common bile duct cyst. Ultrasound showed an echolucent lesion adjacent to the gallbladder, without dilatation of the intrahepatic bile ducts. Laparoscopic cholangiography was performed and confirmed an isolated cystic dilatation of the cystic duct, which was resected laparoscopically, likewise. Conclusions: The incidence of cystic dilatation of the cystic duct is very low and may present in children with variable symptomatology. Diagnosis is usually late, can be suspected by abdominal ultrasound and confirmed by laparoscopic cholangiography, even in the absence of other more modern diagnostic tools. Its recognition and correct classification permit a successful definitive surgical treatment, preferably laparoscopically(AU)

Síndrome de Mirizzi grado IV. Presentación de un caso

El Síndrome de Mirizzi es una afección derivada del impacto de un lito en el conducto cístico o infundíbulo de la vesícula biliar. La enfermedad litiásica, crónica y complicada de la vesícula biliar es un factor determinante. Se presenta el caso de un paciente con historia de íctero obstructivo, al cual se le diagnosticó inicialmente tumor periampular. Fue reevaluado y se le realizaron varias pruebas diagnósticas, hasta llegar al diagnóstico de Síndrome de Mirizzi, corroborado en el acto quirúrgico. El SM es una enfermedad rara de la vía biliar cuyo tratamiento es quirúrgico. La vía laparoscópica para la realización de la colecistectomía es la de elección para casos grado I y en casos seleccionados grado II. La colecistectomía y derivación bilioentérica (hepaticoyeyunostomía) conforman el tratamiento para el resto de los casos.

Mirizzi Syndrome is a condition derived from the impact of a stone in the cystic duct or infundibulum of the gallbladder. Chronic and complicated stone disease of the gallbladder is a determining factor. A patient with a history of obstructive jaundice, who was initially diagnosed with a periampullary tumor is presented. He was reassessed and several diagnostic tests were performed, until reaching the diagnosis of Mirizzi Syndrome, corroborated in the surgical act. MS is a rare disease of the bile duct whose treatment is surgical. The laparoscopic approach to perform cholecystectomy is the one of choice for grade I cases and in selected cases grade II. Cholecystectomy and bilioenteric bypass (hepaticojejunostomy) are the treatment for the rest of the cases.

Morphometric study of extra-hepatic biliary pathways: study in human corpses / Estudio morfométrico de las vías biliares extrahepáticas: estudio en cadáveres humanos

SUMMARY: Adverse events (AE) contribute significantly to postoperative morbidities and comorbidities. Many AEs occur due to a lack of anatomical knowledge and its variants. Latrogenic bile duct injuries, for instance, represent a serious surgical complication of laparoscopic cholecystectomy. Anatomical knowledge for the identification and adequate drainage of all ducts is relevant and fundamental in order to avoid future errors. The objective of the study was to morphometrically analyze the bile ducts in adult human corpses. 13 livers were extracted from adult human corpses to obtain the ducts: choledochal, common hepatic and cystic. After morphological analysis, duct measurements (length and diameter) were continued using a digital caliper. The data obtained were tabulated in SPSS 21 program, performing descriptive analysis with mean and standard deviation. The averages of bile ducts were 61.05 (± 16.43) mm in length and 3.86 (± 0.72) mm in diameter. The cystic duct length and diameter averages were 33.59 (± 12.29) mm and 3.40 (± 0.79) mm, respectively. The common hepatic ducts had an average of 30.02 (± 7.19) mm in length and 3.74 (± 1.18) mm in diameter. The analyzed samples presented different values ?? from those already described in the literature, where the length of the cystic ducts was greater, while the length of the common hepatic ducts was numerically smaller. This work is very significant, as the morphometric variability of the bile ducts allows for varying morphological situations that can compromise the hepatobiliar physiology.

RESUMEN: Los eventos adversos (EA) contribuyen significativamente a las morbilidades y comorbilidades postoperatorias. Muchos EA se deben a la falta de conocimiento de la anatomía y sus variaciones. Por ejemplo, las lesiones iatrogénicas de las vías biliares representan una complicación quirúrgica grave de la colecistectomía laparoscópica. El conocimiento anatómico para la identificación y drenaje adecuado de todos los conductos es relevante y fundamental para evitar futuros errores. El objetivo del estudio fue analizar morfométricamente las vías biliares en cadáveres humanos adultos. Se extrajeron 13 hígados de cadáveres humanos adultos y se retiraron los conductos: colédoco, hepático común y cístico. Después del análisis morfológico, se continuó con las mediciones de los conductos (longitud y diámetro) utilizando un calibrador digital. Los datos fueron tabulados en el programa SPSS 21, mediante análisis descriptivos con media y desviación estándar. Los promedios de las vías biliares fueron de 61,05 (± 16,43) mm de longitud y 3,86 (± 0,72) mm de diámetro. Los promedios de longitud y diámetro del conducto cístico fueron 33,59 (± 12,29) mm y 3,40 (± 0,79) mm, respectivamente. Los conductos hepáticos comunes tenían un promedio de 30,02 (± 7,19) mm de longitud y 3,74 (± 1,18) mm de diámetro. Las muestras analizadas presentaron valores diferentes a los ya descritos en la literatura, donde la longitud de los conductos císticos era mayor, mientras que la longitud de los conductos hepáticos comunes fue numéricamente menor. Este trabajo es significativo, debido a que la variabilidad morfométrica de las vías biliares y permite identificar situaciones morfológicas que pueden comprometer la fisiología hapatobiliar.

Uso del Ligasure® para el sellado del conducto cístico en pacientes intervenidos por colecistectomía laparoscópica / Ligasure® use for cystic duct sealing in patients who underwent laparoscopic cholecystectomy

Con el objetivo de describir el uso del LigaSure® para el sellado del conducto cístico en pacientes intervenidos por colecistectomía laparoscópica en la Sociedad Anticancerosa del Estado Lara, durante el lapso junio 2012-junio 2017, se realizó un estudio descriptivo transversal de recolección retrospectiva de datos de 62 historias clínicas de pacientes intervenidos por colecistectomía laparoscópica asistida por sellado del conducto cístico con LigaSure® los cuales se caracterizaron por un promedio de edad de 47,58 ± 14,11 años, predominio del sexo femenino (64,52%) y un tiempo promedio quirúrgico de 41,74 ± 7,99 minutos. No se registraron complicaciones intraoperatorias ni postoperatorias y la estancia postquirúrgica en 77,42% de los pacientes fue de 24 horas. En conclusión, el uso del LigaSure® para el sellado del conducto cístico resultó una técnica segura para pacientes intervenidos por colecistectomía laparoscópica.

In order to describe LigaSure® use for sealing of the cystic duct in patients who underwent laparoscopic cholecystectomy in the Sociedad Anticancerosa del Estado Lara during the period June 2012-June 2017 we conducted a descriptive transversal study with retrospective data collection of 62 medical charts. Results show that the average patient age was 47.58 ± 14.11 years with a female predominance (64.52%) and an average surgical time of 41.74 ± 7.99 minutes. There was no intraoperative or postoperative complications and the postsurgical stay in 77.42% of patients was 24 hours. In conclusion, the use of LigaSure® for cystic duct sealing is a safe technique for patients who undergo laparoscopic cholecystectomy.

Quiste de conducto cístico / Cystic duct cyst

Los quistes congénitos de la vía biliar son infrecuentes y se definen por la dilatación quística del árbol biliar en cualquiera de sus porciones. Los quistes del conducto cístico son aún menos frecuentes. Su etiología permanece incierta y el tratamiento consiste en la resección debido a su potencial desarrollo de malignidad. Presentamos el caso de una paciente en la que se diagnosticó dilatación del conducto cístico y fue tratada por vía laparoscópica.

Congenital biliary duct cysts are rare and are defined as cystic dilatations of the biliary tree in any of its portions. Cystic duct cysts are more uncommon. Their etiology remains uncertain and they should be resected due to the possible development of malignancy. We report the case of a female patient with a diagnosis of dilation of the cystic duct that was treated with laparoscopic surgery.

Positive cystic duct margin at index cholecystectomy in incidental gallbladder cancer is an important negative prognosticator.

BACKGROUND: Prognostic factors following index-cholecystectomy in patients with incidental gallbladder cancer (IGBC) are poorly understood. The aim of this study was to assess the value of the initial cystic duct margin status as a prognosticator factor and to aid in clinical decision making to move forward with curative intent oncologic extended resection (OER). METHODS: This retrospective study included patients with IGBC who underwent subsequent OER with curative intent at 2 centers (USA and Chile) between 1999 and 2016., Patients with and without evidence of residual cancer (RC) at OER were included. Pathologic features were examined, and predictors of overall survival (OS) were analyzed. RESULTS: The study included 179 patients. Thirty-three patients (17%) had a positive cystic duct margin at the index cholecystectomy. Forty-two patients (23%) underwent resection of the common bile duct. OS was significantly worse in the patients with a positive cystic duct margin at index cholecystectomy (OS rates at 5 years, 34% vs 57%; p = 0.032). Following multivariate analysis, only a positive cystic duct margin at index cholecystectomy was predictive of worse OS in patients with no evidence of residual cancer (RC) at OER (hazard ratio, 1.7 95%CI 1.04-2.78; p = 0.034). CONCLUSIONS: A positive cystic duct margin at index-cholecystectomy is a strong independent predictor of worse OS even if no further cancer is found at OER. In patients with positive cystic duct margin and no RC at OER common bile duct resection leads to improved outcomes.

Gastrinoma of Cystic Duct: A Rare Association With Multiple Endocrine Neoplasia Type 1.

Neuroendocrine tumors (NETs) of cystic duct are extremely rare, accounting for less than 2% of NET cases. The association of biliary tree NET and multiple endocrine neoplasm type 1 (MEN1) are even more rare. In this report, we described a case of a 65-year-old woman who was referred to our neuroendocrine outpatient clinic to investigate MEN1 after an incidental diagnosis of gastrinoma. Her medical history initiated 7 years earlier with severe peptic disease not responsive to proton pump inhibitor therapy. Endoscopic study revealed erosive antral gastritis, erosive duodenitis, bulbar ulcer and pyloric deformity. During follow-up she presented with abdominal pain, chronic diarrhea and weight loss; an ultrasonography was performed and showed only a cholelithiasis. She underwent a video laparoscopic cholecystectomy and all her symptoms were solved. Histopathological study found a 1.0 cm well differentiated NET (Ki-67 labeling index < 2%) located in cystic duct infiltrating the entire wall and subserosa. The MEN1 investigation revealed a primary hyperparathyroidism with a brown tumor in right iliac bone; the patient was referred to a total parathyroidectomy with autotransplantation. No evidence of pituitary tumor was found. The patient remains asymptomatic 24 months after surgery. To conclude, this case highlights an unusual presentation of a cystic duct primary NET gastrinoma in a MEN1 context.

Surgical Considerations of the Cystic Duct and Heister Valves.

Objectives Heister valves are mucosal folds located on the endoluminal surface of the cystic duct (CD) and were first described by Lorenz Heister in 1732. Their presence could represent an obstacle that impedes transcystic exploration. It has been suggested that the distribution of Heister valves follows a steady rhythmic pattern in a spiral disposition; however, there is no conclusive data to support this claim. The aim of this study was to describe the main characteristics of the CD and Heister valves in adult human cadavers. Methods A descriptive cross-sectional study was performed on 46 extrahepatic biliary tracts. Results The CD has an average length of 25.37 mm and diameter of 4.53 mm. The most frequent level of junction was the middle union. Heister valves were present on 32 CDs; in most cases, they were distributed uniformly on the duct and presented an oblique disposition. A nonreticular pattern was the most frequent reticular pattern. The most frequent type of the nonreticular type was the B1 subtype. The most frequent type of distribution was the nonreticular type, particularly the B1 type. Conclusions The cystic fold could hinder transcystic exploration. The cysticotomy incision should not be determined by the distribution of the fold on the CD. The morphology of the Heister valves does not show evidence of a steady systematic pattern.

Anatomic variations of extrahepatic bile ducts and evaluation of the length of ducts composing the cystohepatic triangle / Variaciones anatómicas de los ductos biliares extrahepáticos y longitud de los ductos del trígono hepato-cístico

It is of paramount importance for surgeons to have a thorough knowledge of the normal anatomy of the extrahepatic bile ducts and its variations due to the high frequency with which they perform in this anatomic site. The cystohepatic triangle, or Calot's Triangle, is bound by the cystic duct, common hepatic duct, and the hepatic border; therefore, its surface area depends on the conformation of these ducts and is closely linked to surgical procedures performed in this region. It has been reported that the length and the position of these ducts may be related to the formation of bile duct stones, Mirizzi's syndrome, and bile duct cancer. Thus, the present work aims to analyze the configuration of the extrahepatic biliary tree and its possible variations, as well as measure the components that make up the cystohepatic triangle. For this task 41 samples from fixated human cadavers were analyzed, with 25 consisting of anatomic parts (liver and biliary tree) and 16 in situ samples. The extrahepatic biliary trees were dissected in order to measure the length of the common hepatic and cystic ducts with a digital caliper, and all anatomic variations were registered. The length of the common hepatic duct varied between 4.18 mm and 50.64 mm, with an average of 21.76 +/- 9.51 mm. The length of the cystic duct varied between 7.28 and 38.88 mm, with an average of 19.11 +/- 6.77 mm. Anatomic variations were found in 3 samples (7.3 percent): in one of them the cystic duct connected to the left hepatic duct; in another, the cystic duct connected to the right hepatic duct; in the third, there was a triple confluence of hepatic ducts (two right ducts and one left duct). The results are a contribution to the clinical and surgical anatomy of this region.

El conocimiento de la anatomía normal de las vías biliares extrahepáticas y sus variaciones es fundamental para los cirujanos digestivos debido a la frecuencia con que se actúa en esa región. El trígono hepato-cístico o de Calot es delimitado por el ducto cístico, ducto hepático común y el margen del hígado. De este modo, su área depende de la conformación de esos ductos y está íntimamente relacionada a procedimientos quirúrgicos efectuados en esa zona. Se ha señalado que la longitud y la disposición de esos ductos estarían involucradas en la formación de cálculos biliares, síndrome de Mirizzi y neoplasias de vías biliares. Así, el presente estudio tuvo como objetivo analizar la configuración de las vías biliares extrahepáticas y sus posibles variaciones, además de registrar parámetros métricos de los componentes del sistema biliar que integran el trígono hepato-cístico. Para el estudio se utilizaron 41 muestras de cadáveres formolizados de individuos adultos, siendo 25 piezas anatómicas (de hígado y vías biliares) y 16 in situ. Las vías biliares fueron disecadas, esquematizadas y fotografiadas, se registró la longitud del ducto hepático común y cístico con un caliper digital. La longitud promedio del ducto hepático común fue de 21,76 +/- 9,51 mm, variando de 4,18 mm a 50,64 mm; la longitud promedio del ducto cístico fue de 19,11 +/- 6,77 mm, variando de 7,28 a 38,88 mm. Se observaron variaciones en 3 muestras (7,3 por ciento), en una de ellas, el ducto cístico se unió al ducto hepático izquierdo, en otra, el ducto cístico se unió al ducto hepático derecho y en la otra muestra, se presentó una confluencia triple de ductos hepáticos, dos derechos y uno izquierdo. Los resultados obtenidos son un aporte a la anatomía clínica y quirúrgica de la región.

Litíase sintomática em vesícula biliar residual / Symptomatic lithiasis in residual gallbladder

Sintomas pós-colecistectomia muitas vezes tem causas extra-biliares. As causas biliares mais comuns são presença de cálculos ou cirurgia incompleta. O uso da colangiorressonância magnética pode evitar complicações intraoperatórias decorrentes anatomia biliar pouco usual facilitando o acesso cirúrgico. No presente trabalho é relatado caso de paciente com litíase sintomática em vesícula residual.

Most post cholecystectomy symptoms have extrabiliary causes. The most common biliary causes are calculi and incomplete surgery. The use of magnetic resonance cholangiography (MRC) seems to avoid intraoperative complications due to a possible unusual biliary anatomy and to facilitate surgical access. Here in is reported a case of patient with symptomatic lithiasis in residual gallbladder.

Thyroglossal duct cyst

Thyroglossal duct cysts (TDCs) are cervical cysts occurring inapproximately 7% of the population, mainly during childhood. Thecyst usually presents itself as a painless, asymptomatic midlineswelling below the hyoid bone. Differential diagnosis involves branchialcleft cyst, lymphoepithelial cyst, thyroid gland lesions, ranula andlymphadenopathy (of various etiologies). Sonogram (ultrasound) isthe most frequent and appropriate imaging modality in suspectedTDC. Preoperative fine-needle aspiration is an inexpensive and safemethod that can be considered in selected adult patients, having primeimportance to the exclusion of carcinoma. This article presents a TDCof the neck in a 5-year-old boy.

Necrose do coto do ducto cístico após colecistectomia videolaparoscópica / Post-videolaparoscopy cholecystectomy necrosis of the cystic duct

INTRODUÇÃO: Lesões das vias biliares, embora não frequentes, podem ser visualizadas ou percebidas no ato operatório. Porém, as derivadas de necrose por manipulação são tardias e não reconhecíveis durante a operação. RELATO DO CASO: Paciente submetida à colecistectomia videolaparoscópica apresentou coleperitônio no pós-operatório. Em re-operação observou-se ducto cístico fistuloso no local da clipagem dupla. Realizada drenagem intra-cística. Evoluiu com bilioma associado que necessitou também de drenagem por aspiração. Evoluiu satisfatoriamente e com cura em um mês. CONCLUSÃO: Por ser uma situação rara, ainda não existe consenso sobre suas principais causas e incidência.

BACKGROUND: Biliary iatrogenic lesions in cholecistectomies are not frequent, but can be treated at the same procedure, if recognized. Necrotic lesion, by the other hand, no. CASE REPORT: Woman submitted to videolaparoscopic cholecystectomy presented, on early follow-up, acute peritonitis due to necrosis of cystic duct on the clips site. Was operated to drain the duct through the introduction of a nasogastric tube inserted in cystic ostium in the necrotic area. Drainage of a bilioma in the epigastrium was also needed after one week, guided by ultrasound. The case had good evolution in one month. CONCLUSION: Due to the rare condition, the management of biliary fistula in necrotic area remains controversial.

Colecistectomia laparoscópica em um paciente com ducto cístico duplo / Laparoscopic cholecystectomy in a patient with duplicated cystic duct

Our objective is to report a case of laparoscopic cholecystectomy in a patient with duplicated cystic duct. A 34 year old male presented with episodic pain in the upper rigth quadrant of the abdomen. Murphy' s sign was not present. Ultrassonography showed gallbladder with multiple calculi and a thickened wall. At laparoscopic cholecystectomy, a duplicated cystic duct was found. Careful dissection and intraoperative cholangiography were performed to rule out common bile duct injury.

Ligadura del conducto cístico: Colecistotomía y exTracción de cálculos vesiculares

Se realizó la ligadura del conducto cístico y extracción de cálculos en un paciente operado de urgencia, en el cual habían grandes dificultades técnicas para el abordaje de la vía biliar. Esto dio lugar a un estudio en animales, cuyos resultados fueron satisfactorios. Una vez sacrificados los animales se comprobó atrofia de la vesícula biliar sin complicaciones. El informe anatomopatológico destacó fibrosis. Se escogió un grupo de pacientes sintomáticos, que requerían colecistectomía y presentaban cirrosis hepática. Se les operó con aplicación de esta técnica por vía normal y laparoscópica. Los únicos requisitos técnicos fueron la ligadura del conducto cístico, extracción de cálculos y adecuada aspiración de la vesícula biliar. Se obtuvieron buenos resultados con un mínimo de disección, sin complicaciones, con una anestesia y tiempo quirúrgico mínimo y con una técnica fácil y asequible a cualquier cirujano y en cualquier medio. Este proceder beneficiaría a los pacientes cirróticos.

The ligation of the cystic duct and the extraction of gall stones were performed in urgently operated patient with great technical difficulties for the approach of the biliary tract: This led to conduct a study of animals with satisfactory results. Once the animals were sacrified it was observed gall bladder atrophy without complications. Fibrosis was stressed in the anatomopathological report. A group of symptomatic patients who required cholecystostomy and suffered from liver cirrhosis were chosen and operated on by using this technique by normal and laparoscopic pathway. The only technical requirements were the ligation of the cystic duct, the extraction of gall stones and the adequate aspiration of the gall bladder.