Recognition and Surgical Management of Aberrant Right Hepatic Duct Originating From the Cystic Duct.

An aberrant right hepatic duct is a rare congenital anomaly of the biliary system. Failure to recognize these anomalies can result in serious complications. In this case, we present a patient who underwent laparoscopic cholecystectomy for chronic cholecystitis. Post-operatively she developed a bile leak for which she underwent reoperation. On re-exploration, she was discovered to have a cystic stump leak and a rare Hisatsugu type V anatomic anomaly of the right hepatic duct originating from the cystic duct. She was subsequently managed with oversewing of the cystic duct stump and drainage. This case demonstrates the importance of recognizing these rare anomalies and the challenges of management in a rural, resource-limited setting.

Duplicated gallbladder: an incidental anatomical variation in a patient with symptomatic cholelithiasis.

Congenital malformations of the biliary tract represent a relatively rare entity with which surgeons, radiologists and clinicians are not adequately familiarized. We present a rare case of gallbladder duplication in a 40-year-old female, with the accessory cystic duct entering the left hepatic duct, which depicts the fifth reported case in the international bibliography. Our case illustrates the importance of detailed knowledge of anatomical malformations of the biliary tree, serving the purpose of a preoperative diagnosis of symptomatic cholelithiasis. It is also of paramount importance to take under consideration biliary tract malformations to avoid inadvertent complications such as biliary duct injuries in case of laparoscopic cholecystectomy.

A systematic review of the anatomical findings of multiple gallbladders.

BACKGROUND: Multiple gallbladders (MG) are a rare malformation, with no clear data on its clinical impact, therapeutic indications or risk for malignancy. METHODS: A systematic review of all published literature between 1990 and 2017 was performed using the PRISMA guidelines. RESULTS: Data of 181 patients extracted from 153 studies were reviewed. MG were diagnosed during the treatment of a gallstone-related disease in 83% of patients, of which 13% had previous cholecystectomy and had a recurrence of biliary stone disease. The sensitivity of ultrasound scan was 66%, and that of magnetic resonance imaging cholangio-pancreatography, 97%. The cystic duct was common to both gallbladders (type1) in 43% and separated (type 2) in 50% of patients. In the latter case, there was no way to differentiate preoperatively an accessory gallbladder from a Todani II bile duct cyst. Cholecystectomy was performed in 129 patients by laparotomy (43%) or laparoscopy (56%). MG was undiagnosed before surgery in 24% of the patients. The postoperative biliary leakage rate was 0.7%. In two patients, gallbladder cancers were detected. CONCLUSION: MG are difficult to diagnose and share a common natural history with single gallbladders, without evidence of increased risk for malignancy. Excision of both gallbladders is indicated in symptomatic stone disease. However, prophylactic cholecystectomy must be considered for type 2 MG, since it cannot be preoperatively differentiated from a Todani II bile duct cyst, which is associated with a risk of malignant transformation.

Multidetector CT in detection of troublesome posterior sectoral hepatic duct communicating with cystic duct.

OBJECTIVE: To investigate whether multiple detector CT (MDCT) could detect troublesome aberrant posterior sectoral hepatic duct (PHD) communicating with cystic duct (CD). METHODS: The most troublesome bile duct anomaly during cholecystectomy is an aberrant PHD communicating with CD. It has been suggested that an unenhanced small duct between Rouviere's sulcus and CD on MDCT could be coincident to an aberrant PHD communicating with CD. A total of 224 patients who underwent laparotomy with complete lymph node dissection in the hepatoduodenal ligament for hepatobiliary or pancreatic tumour were enrolled. Retrospective review of preoperative MDCT images and surgical records was performed. RESULTS: Preoperative MDCT detected 8 (3.6%) unenhanced ducts between Rouviere's sulcus and CD. Surgical records identified 7 (3.1%) cases of aberrant PHD communicating with CD, and all 7 cases showed an unenhanced duct between Rouviere's sulcus and CD on preoperative MDCT imaging. Among the 7 patients, 5 (71%) were without bile duct dilatation. CONCLUSION: MDCT could detect troublesome aberrant PHD communicating with CD, regardless of the presence or absence of bile duct dilatation. Advances in knowledge: MDCT could detect most troublesome PHD communicating with CD, regardless of the presence or absence of bile duct dilatation.

Magnetic Resonance (MR) Cholangiopancreatography Demonstration of the Cystic Duct Entering the Right Hepatic Duct.

BACKGROUND MR cholangiopancreatography is widely performed before laparoscopic cholecystectomy to rule out choledocholithiasis and to avoid iatrogenic injuries that may be related to the high frequency of anatomical variations of the biliary tree. Although most of these variants have already been demonstrated surgically and by endoscopic retrograde cholangiopancreatography and CT cholangiography, there are no references in which MR cholangiopancreatography has shown a cystic duct draining into the right hepatic biliary duct. CASE REPORT A 51-year-old woman with a history of recurrent abdominal pain underwent an abdominal ultrasound in an outside center, which revealed gallbladder cholelithiasis. In this patient, an MR cholangiopancreatography was performed and the laboratory data were obtained. Laboratory findings showed only a mild increase of cholestasis. MRCP did not reveal significant dilatation of intra- or extrahepatic biliary ducts, while the cystic duct showed an atypical insertion, draining directly into the right hepatic duct. CONCLUSIONS To avoid unintentional bile duct injuries, MRCP evaluation of the biliary anatomy is particularly important for pre-operative evaluation of patients undergoing laparoscopic cholecystectomy. In particular, in the case we describe, the right hepatic duct might have been mistaken for the cystic duct, with potentially severe surgical complications and clinical consequences.

Intrahepatic biliary duct branching patterns, cystic duct anomalies, and pancreas divisum in a tertiary referral center: A magnetic resonance cholangiopancreaticographic study.

BACKGROUND: Knowledge about anatomic variations in intrahepatic biliary ducts (IHBD) is relevant for performing biliary drainage and for avoiding bile duct injury during cholecystectomy and liver resections. Low insertion of cystic duct (LICD) is a common anatomic variant. Pancreas divisum is the commonest congenital anomaly of pancreas; it has been causally linked with recurrent acute pancreatitis (RAP). METHODS: Magnetic resonance cholangiopancreaticography (MRCP) images of 500 consecutive patients were reviewed for anatomic variants of IHBD, cystic duct, and pancreatic duct. RESULTS: Anatomy of IHBD could be evaluated in 458 MRCP's, of these 301 (65.72 %) had 'typical' anatomy. The variant in 157 persons included 'triple confluence' in 56 (12.23 %), 'right posterior segmental duct (RPSD) draining to left hepatic duct (LHD)' in 64 (14 %), 'RPSD to common hepatic duct (CHD)' in 20 (4.4 %), 'RPSD to cystic duct' in 2 (0.4 %), 'accessory duct to CHD' in 3 (0.7 %), 'accessory duct to right hepatic duct (RHD)' in 1 (0.2 %), 'segment 2 and 3 separately to CHD' in 1 (0.2 %), and complex variants in 10 (2.2 %). Cystic duct could be evaluated in 338 patients; of these, 15 (4.4 %) had LICD. Patients with RAP had pancreas divisum more often than those without any pancreatic disease, (-/-,10 % and -/-, 0.8 %; p = 0.004). CONCLUSIONS: Nearly one third of MRCPs showed atypical IHBD pattern with RPSD draining to LHD being the commonest. LICD was the most common cystic duct variant. Pancreas divisum was more frequent in patients with RAP than in persons without pancreatic disease.

Rare case of gallbladder agenesis presenting with pancreatitis.

Gallbladder agenesis (GA) is a rare congenital abnormality with an incidence of 0.01-0.09%. Majority of GA exist alone although it can be associated with other systemic malformations involving the gastrointestinal, genitourinary, cardiovascular and skeletal systems. It is thought that biliary and pancreatic pathologies coexist and this is the second case reported in the literature of GA presenting with pancreatitis.

Management of gallbladder duplication using a single-site robotic-assisted approach: a case study.

Gallbladder duplication is a rare congenital anomaly. Here, we describe a 29-year-old female who presents with classic symptoms of biliary colic. A duplicated gallbladder was recognized on preoperative ultrasound. This case report reviews a single-site robotic-assisted cholecystectomy with a cystic duct duplication. The patient underwent the surgery without complication. Due to the aberrant anatomy of the cystic triangle, it was decided to mobilize the gallbladder in a dome-down fashion. True gallbladder duplication can be categorized according to cystic duct orientation based on Boyden's classification. Preoperative diagnosis is essential to prevent surgical complications. A laparoscopic approach can be carried out safely in the hands of a skilled surgeon. This case report shows that the robotic-assisted surgical approach is a viable and safe alternative.

[Gallbladder agenesis. Case report]. / Agenesia de la vesícula biliar. Reporte de caso.

BACKGROUND: Gallbladder agenesis is a very rare congenital abnormality of the biliary tract. The diagnosis is made during surgery, because all preoperative studies have failed to identify this malformation. The purpose of this article is to present a case of gallbladder agenesis diagnosed during surgery, its management, and a review of the literature. CLINICAL CASE: The case involves a sixty-two year- old female, referring to repeated biliary colic symptoms. The abdominal ultrasound diagnosed cholelithiasis. It was impossible to identify the gallbladder during surgery. Diagnosis was confirmed by intra-operative cholangiography. DISCUSSION: Preoperative diagnostic workup has failed to recognise patients with gallbladder agenesis. It is currently recommended to abandon the surgery once this diagnosis is suspected and confirm it by a cholangio-magnetic resonance scan in order to avoid a bile duct injury. CONCLUSIONS: Agenesis of the gallbladder is a rare congenital abnormality of the biliary tree. Every surgeon must keep this rare entity in mind when a "difficult dissection" or an anatomic variant is identified during surgery, and make use of an intra-operative cholangiography, mainly to prevent a bile duct injury.