Aberrant subvesical bile ducts identified during laparoscopic cholecystectomy: A rare case report and review of the literature

The Duct of Luschka: An Anatomical Variant of the Biliary Tree - Two Case Reports and a Review of the Literature

Anatomical variations occurring in the bile ducts, including the duct of Luschka, are very common. It is essential for radiologists and surgeons to understand these anomalies so they can diagnose them before and during the surgery to prevent postoperative complications. In this report, we present the case of two patients who were admitted to the emergency department for abdominal pain and fever following cholecystectomy. Postoperative imaging led to the diagnosis of injury to the duct of Luschka.

Rare bile leak from left triangular ligament

Variations of the biliary system present challenges to abdominal operations and can affect postoperative outcomes. Bile leak is an uncommon complication of total gastrectomy. However, any procedure that involves mobilisation of the left lobes of the liver should be executed with additional caution. A thorough assessment including preoperative imaging for aberrant anatomy should be performed, especially aberrant bile ducts in the left triangular ligament. Ligation or suturing of the left triangular ligament should be considered when the aberrant anatomy suggests, to decrease the risk of postoperative bile leak. In addition, the left lateral segment of the liver should be thoroughly inspected on initial completion of the operation.

Two Cases of Subvesical Bile Duct Injury Detected and Repaired Simultaneously during Laparoscopic Cholecystectomy

Introduction

Subvesical bile duct (SVBD) injury is a secondary major cause of minor bile duct injury after laparoscopic cholecystectomy (LC). However, this injury is usually not recognized intraoperatively, but postoperatively.

Case Report

Case 1: the patient was an 84-year-old female, preoperatively diagnosed with acute cholecystitis. During LC, a tiny hole in the gallbladder fossa from which bile juice oozing was confirmed. Suturing was performed laparoscopically. Case 2: the patient was an 81-year-old male, preoperatively diagnosed with cholelithiasis. Because of a previous history of gastrectomy, laparoscopic adhesiolysis around the gallbladder was performed. During dissection, a small amount of bile was oozing from the surface of the liver adjacent to the gallbladder fossa. Suturing was performed laparoscopically.

Conclusion

If a small amount of bile juice was detected, meticulous observation not only around the cystic duct stump but also the gallbladder fossa should be performed. Simultaneous laparoscopic suturing was feasible, and an ideal procedure against SVBD injury developed during LC.

Efficiency of fluorescent cholangiography during laparoscopic cholecystectomy for subvesical bile ducts: A case report

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The subvesical bile ducts are important from the potential risk for bile leakage.

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It is difficult to identify the subvesical bile ducts intraoperatively.

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Fluorescent cholangiography visualized the subvesical bile ducts clearly.

Introduction

The subvesical bile ducts are located in the peri-hepatic connective tissue of the gallbladder fossa. Injury of the subvesical bile ducts provokes the severe complication of bile leak. Until now, fluorescent cholangiography has been employed during hepatobiliary surgery. Herein, we report the detection of subvesical bile ducts by fluorescent cholangiography during laparoscopic cholecystectomy.

Presentation of case

A 63-year-old female was admitted to our department for surgery for symptomatic cholelithiasis. The subvesical bile ducts were not observed on drip-infusion cholangiography with computed tomography. Immediately following induction of anesthesia, 2.5 mg of indocyanine green was intravenously injected. Fluorescent cholangiography demonstrated two thin aberrant bile ducts during dissection of Calot’s triangle. We considered them to be subvesical bile ducts. We ligated them with clips, divided them, and then performed laparoscopic cholecystectomy using a standard procedure. The patient had a good post-operative recovery without bile leakage. Postoperative laboratory test results were all within normal limits. Computed tomography revealed no dilatation of the intrahepatic bile duct after laparoscopic cholecystectomy. The patient was discharged on postoperative day 4.

Discussion

Injury to the subvesical bile ducts is one of the most common causes of bile leakage associated with cholecystectomy. Fluorescent cholangiography enabled real-time identification of the thin subvesical bile ducts, which were undetectable by drip-infusion cholangiography with computed tomography.

Conclusion

Fluorescent cholangiography during laparoscopic cholecystectomy may be useful for preventing postoperative bile leakage.

Intraoperative Treatment of Duct of Luschka during Laparoscopic Cholecystectomy: A Case Report and Revision of Literature

Background

Bile leakage still remains a serious complication during cholecystectomies. In limited cases, this complication may occur from injury of the so-called ducts of Luschka. These rare ducts are usually discovered intraoperatively, and their presence poses the risk of bile injury and clinically significant bile leak.

Presentation Case

We present a unique case of a 59-year-old male patient with acute cholecystitis. After removal of the gallbladder, thorough inspection of the hepatic bed was made and a little bile leak was identified from a duct of Luschka 1 cm away from the gallbladder hilum. We report on the use of endoscopic QuickClip Pro® clips (Olympus Medical Systems Corp., Tokyo, Japan) to avoid further more invasive treatment.

Discussion

Endoscopic retrograde cholangiopancreatography with sphincterotomy played a crucial role for diagnosis and treatment of bile leaks with success rate near 94%. Many authors have argued the role of relaparoscopy, Diagnosis may be intraoperatively but this option does not seem to occur very often; in fact, there is a lack of data in literature.

Conclusion

This is the first case report of bile leak from duct of Luschka treated during the cholecystectomies with endoscopic clip.

Laparoscopic cholecystectomy with aberrant bile duct detected by intraoperative fluorescent cholangiography concomitant with angiography: A case report

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Usefulness and safety of combined vascular and biliary fluorescent ICG imaging during laparoscopic cholecystectomy was reported.

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Aberrant bile ducts are rare anatomical variation and clinically important because of the susceptibility to injury during cholecystectomy.

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We encountered a case of laparoscopic cholecystectomy with an aberrant bile duct detected by intraoperative fluorescent cholangiography concomitant with angiography.

Introduction

Laparoscopic cholecystectomy is the standard surgical treatment for patients with benign gallbladder disease. However, bile duct injury continues to be reported as a surgical complication. Intraoperative cholangiography is recommended to reduce the risk of bile duct injury during laparoscopic cholecystectomy. Intraoperative cholangiography using indocyanine green, which is excreted into bile and shows fluorescence under infrared light, has recently been reported as useful in preventing bile duct injury during laparoscopic cholecystectomy. We report here a case of laparoscopic cholecystectomy with an aberrant bile duct detected by intraoperative fluorescent cholangiography concomitant with angiography.

Presentation of case

An 82-year-old woman was diagnosed with cholecystolithiasis and underwent laparoscopic cholecystectomy. An aberrant bile duct branching from the right side of the common hepatic duct was detected by intraoperative indocyanine green fluorescent cholangiography. Furthermore, we were able to confirm the cystic artery by reinjecting indocyanine green during the procedure. Laparoscopic cholecystectomy was performed safely without injuring the aberrant bile duct, despite no recognition of the abnormality on preoperative computed tomography or magnetic resonance imaging.

Discussion and conclusions

Aberrant bile ducts are rare anatomical variation and clinically important because of the susceptibility to injury during cholecystectomy. Our case reported for the first time that fluorescence cholangiography concomitant with angiography was useful for identifying an aberrant bile duct and the cystic artery during laparoscopic cholecystectomy.