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.

[Duplication of the gallbladder and cystic duct as a rare finding during cholecystectomy - a case report]

Congenital anomalies of the gallbladder, the biliary tract and their vasculature are relatively common. They usually represent only anatomical variations that may not manifest clinically, but in some cases they are of fundamental importance for the surgeon as they can cause diagnostic confusion or lead to problems during surgery. Their ignorance may result in many errors, injury during surgery and subsequent serious consequences. Genuine duplication of the gallbladder with the cystic duct and its artery is extremely rare and is therefore still only a subject of case reports. Gallbladder duplication itself is not an indication for surgery. If it contains stones or if inflammation occurs, however, both gallbladders may not be affected equally and if this variety is not recognized, only one of them may be removed and the other one can escape attention. The case report describes the rare case of gallbladder duplication including the cystic duct during elective cholecystectomy in a middle-aged man who was operated on after birth for omphalocele. Preoperative diagnostic examination described malrotation of the intestine and a cystic lesion next to the gallbladder, considered to be rather a liver cyst. Although it was indeed possible to assume various other abnormalities in the anatomical arrangement of the organs with regard to the patients history, the finding of double gallbladder including cystic duct was still surprising.

Anatomical and congenital anomalies of extra hepatic biliary system encountered during cholecystectomy

Anomalous biliary anatomy is frequently encountered by surgeons during cholecystectomy. Importance of its recognition lies in avoiding serious biliary injuries. This study was carried out to assess the frequency of anatomical and congenital anomalies of extrahepatic biliary system in patients undergoing cholecystectomy. This is an observational study performed in the Department of Surgery, Combined Military Hospital (CMH) Momenshahi, CMH Ghatail and Mymensingh Medical College Hospital for a period of five years from June 2007 to June 2012. Two hundred and fifty diagnosed patients of cholelithiasis undergoing routine cholecystectomy were assessed for anatomical and congenital anomalies of extra hepatic biliary system as well as vascular anomalies. Structures mainly assessed for anomalies were gall bladder, cystic duct, supraduodenal part of Common Bile Duct (CBD), cystic artery and hepatic artery which are routinely handled during cholecystectomy. However, assessment of variations and anomalies, of hepatic ducts, portal vein, retroduodenal and pancreatic parts of CBD were not done due to possibility of iatrogenic injuries. Two hundred and fifty cases of cholelithiasis comprising 216(86.4%) females and 34(13.6%) males with mean age of 39.15 years were included in the study. Clinical presentation includes mainly pain in right hypochondrium (74.8%), pain in right hypochondrium and epigastrium (18.8%) and pain in epigastrium alone (7.6%). Laparoscopic cholecystectomy was done in 157 patients and 93 patients were treated by open procedure including conversion cases. Operative findings revealed variations in 38 cases (15.2%) mainly involving cystic artery (8%), cystic duct (4.4%) and gall bladder (1.6%). Postoperative complications includes bleeding 3.6%, biliary leak from drain 1.6% and CBD injury 0.8% giving rise to 0.8% morbidity, however, no mortality was seen in this series. Anatomical and congenital anomalies of biliary tree, are not common but may be significant during surgery as failure to recognize them leads to iatrogenic injuries and can increase morbidity and mortality.

Isolated congenital agenesis of the gallbladder and cystic duct: report of a case

Congenital agenesis of the gallbladder and cystic duct represents a rare anomaly of the biliary system. It likely results from an embryologic mishap in the development of the hepatobiliary bud and can occur with other associated malformations. We report the case of congenital absence of the gallbladder and cystic duct incidentally found during laparoscopy in a 44-year-old Caucasian female. Based on the clinical presentation and ultrasonography findings, the patient was presumed to have symptomatic cholelithiasis and chronic cholecystitis. A laparoscopic cholecystectomy was planned. After introducing the laparoscope, the gallbladder and cystic duct were absent and the procedure aborted. Gallbladder and cystic duct agenesis was confirmed by magnetic resonance cholangiopancreatography. We describe here the difficulties with diagnosis and pain management, and review the literature of this rare pathology.

Duplicated gallbladder: surgical application and review of the literature

Duplicated gallbladder is a rare congenital anomaly, usually asymptomatic and occurring as incidental radiographic or surgical finding during upper abdomen, liver and extrahepatic biliary tract surgery. We report on a case of two separate gallbladders, one main and one accessory, each one with its own cystic duct. The main cystic duct drained into the common bile duct while the accessory bile duct extruded into the left side of common bile duct just inferior to the main cystic duct termination. Imaging advances such as computerized tomography, intraoperative endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography may aid in the establishment of accurate diagnosis. The anomaly is of great importance because the surgeon may miss the main or the accessory gallbladder and the patient may need to be re-operated in case of cholelithiasis.

[Laparoscopic approach in gallbladder agenesis--an intraoperative surprise]

INTRODUCTION

The congenital absence of the gallbladder in the absence of biliary atresia is extremely rare, world literature recognizing only 413 cases. The aim of this study is to clarify the diagnostic and therapeutic approach of this rare condition.

METHOD

There were retrospectively analyzed the first 2 cases of gallbladder agenesis admitted and surgically approached in the Emergency Hospital, Bucharest.

RESULTS

The first case (woman, 23 years old) had typically biliary complaints at admission, shrinked gallbladder and lithiasis on ultrasound. There was a laparoscopic approach but we didn't find any gallbladder. After a non-therapeutic laparoscopy the biliary symptoms disappeared. In the second case (woman, 52 years old) the admission was for upper abdominal quadrant colicative pain and the transparietal abdominal ultrasound showed chronic cholecystitis. Common bile duct dilatation was revealed during laparoscopy. After conversion to laparotomy there was performed intraoperative colangiography, but no other biliary pathology was revealed. The initial complaints also disappeared after surgery.

CONCLUSIONS

We find the laparoscopic approach an effective method for the diagnosis of gallbladder agenesis. Postoperative Magnetic Resonance Cholangiopancreatography represents a very useful imagistic tool to rule out an intrahepatic gallbladder.

Endoscopic therapy for type B surgical biliary injury in a patient with short cystic duct

Anatomical variations of the cystic duct are well-defined. The presence of short or absent cystic duct is unusual and represents a co-factor of biliary injury especially during laparoscopic cholecystectomy. Thus, its knowledge is important to avoid ductal injury in hepato-biliary surgery. We experienced the case of a 40-year-old woman with symptomatic cholelitiasis, who underwent to laparoscopic cholecystectomy. At surgery, an accidental bile duct lesion was carried, during Calot's triangle dissection, due the particular difficulties in dissecting an extremely short cystic duct found at the junction of the common hepatic duct and common bile duct. No vascular anomalies were present. The biliary leakage from the common bile duct was intraoperative identified and subsequentially treated by the endoscopic method. Laparoscopic cholecystectomy with sequential biliary endoprosthesis insertion was completed without conversion to open surgery. The endoscopic stenting was the definitive treatment for the leakage. No evidence of biliary stent complication was observed during the follow-up. This report documents a case of short cystic duct with particular emphasis to the biliary injury risk during the laparoscopic dissection of "unusual" Calot's triangle, and examines our mini-invasive therapeutic strategies in the management of bile leakage after laparoscopic cholecystectomy.

[Anatomy and variants of hepatic segments, vessels, and bile ducts]

Knowledge of normal liver anatomy and its variants is indispensable for the radiologist. Accurate assessment of anomalies of the arterial, portal (venous), and biliary system and of liver segments using computed tomography is necessary for consultation with the surgeon and deciding on the therapeutic strategy. The multidetector CT is the most important tool for preoperative evaluation. Alternatively, MRI can be used with special regard to the biliary system (MRCP). This article reviews the most important variants of the liver detected with imaging modalities and their clinical relevance.

Double cystic duct in a child with VACTERL association: a case report

Double cystic duct is an extremely rare anomaly of the biliary tract not described in the pediatric literature. We report the first pediatric case born with VACTERL association found to have double cystic ducts during gallbladder surgery for symptomatic cholelithiasis. Description of the anatomic variability, cholangiography images, and pathologic findings along with review of the literature is included.

Long, parallel cystic duct in laparoscopic cholecystectomy for acute cholecystitis: the role of magnetic resonance cholangiopancreatography

Congenital malformation of the gallbladder and cystic duct that cause operative difficulty are rare developmental abnormalities of embryogenesis. We report the case of a 47-year-old male patient who presented with right upper quadrant pain, tenderness, mild jaundice, moderately elevated liver function tests, and ultrasound evidence of acute calculus cholecystitis. Magnetic resonance cholangiopancreatography (MRCP) excluded choledocholithiasis, but revealed the cystic duct anomaly. A difficult laparoscopic cholecystectomy was performed successfully. This is an unusual case of laparoscopic cholecystectomy for severe acute calculus cholecystitis in a patient with very low conjunction to the common bile duct (CBD) of a long, parallel cystic duct.

Gallbladder agenesis with a stone in the cystic duct bud

An 84-year-old woman was admitted to the hospital because of pyloric stenosis caused by gastric cancer. Abdominal computed tomography and magnetic resonance imaging failed to demonstrate the gallbladder, but showed a gallstone in a duct-like structure parallel to the common bile duct. When laparotomy was performed, the gallbladder and the fossa were not observed, and a blind-end duct, similar to a cystic duct, was found beside the common bile duct. Incisional exploration of the common bile duct was done after distal gastrectomy; the gallstone was not found in the common bile duct, but in the duct parallel to it. By observing the duct beneath the common bile duct with a cholangioscope, we considered it to be a hypoplastic cystic duct. After the gallstone was removed, a T-tube was placed into the common bile duct. Agenesis of the gallbladder is a rare congenital anomaly and is often asymptomatic. As far as we know, this is the first report of gallbladder agenesis with a hypoplastic cystic duct impacted with a stone. Careful intraoperative examination using a cholangioscope is useful to confirm the structure of the common bile duct.

Mirizzi syndrome in an anomalous cystic duct: A case report

Mirizzi syndrome is a rare complication of gallstone disease, and results in partial obstruction of the common bile duct or a cholecystobiliary fistula. Moreover, congenital anatomical variants of the cystic duct are common, occurring in 18%-23% of cases, but Mirizzi syndrome underlying an anomalous cystic duct is an important clinical consideration. Here, we present an unusual case of typeIMirizzi syndrome with an uncommon anomalous cystic duct, namely, a low lateral insertion of the cystic duct with a common sheath of cystic duct and common bile duct.

Clinical significance of the confluence of the cystic duct in patients with anomalous arrangement of the pancreaticobiliary duct

BACKGROUND/PURPOSE

In anomalous arrangement of the pancreaticobiliary duct (AAPBD), there is anatomical diversity of the cystic duct. In this study, we evaluated the influence of the level of insertion of the cystic duct into the extrahepatic bile duct on the pathophysiology of AAPBD.

METHODS

Thirty-two children with AAPBD were examined using cholangiopancreatography. If the cystic duct entered the hepatic duct at the lower middle point of the extrahepatic bile duct, it was defined as low confluence; otherwise, it was considered as high confluence. Clinical details and radiological variables were compared between these 2 groups.

RESULTS

Low confluence was noted in 8 of the 32 patients. Seven of the 8 had fusiform-type or nondilatation-type choledochus, and the cystic-type was significantly less frequent than in the high-confluence group. The diameter of the common bile duct was significantly smaller and the main pancreatic duct was significantly greater than in the high-confluence group. Pancreatitis was more common and biliopancreatic reflux on computed tomography combined with intravenous infusion cholangiography was more often seen in the low-confluence group than in the high-confluence group.

CONCLUSIONS

Bile juice could regurgitate into the pancreatic duct via the low confluence of the cystic duct, resulting in severe pancreatitis in patients with AAPBD.

Laparoscopic cholecystectomy for left-sided gallbladder: report of two cases

We report two cases in which patients, who had different junctions of the cystic duct with the common bile duct (CBD), with left-sided gallbladders were treated with laparoscopic cholecystectomy. The first patient, a 69-year-old man, could be diagnosed intraoperatively, and his cystic duct joined the CBD from the right side. The gallbladder of the second patient, a 52-year-old woman, was located on the left side of the CBD, and the cystic duct entered the left hepatic duct directly. In both instances, successful laparoscopic cholecystectomy was performed, and the patients recovered uneventfully. We describe these cases and discuss the key procedures for safe laparoscopic cholecystectomy for a left-sided gallbladder from our experience and a review of the relevant literature.

An accessory double cystic duct with single gallbladder

A case of double cystic duct was detected during preparation of cadavers for educational purposes in a 76 year old woman. The two cystic ducts formed a triangular formation with the common hepatic duct. That is the fifteenth reported case in the literature. We report on the exact description of the macroscopic anatomy of that rare congenital abnormality, the pathogenesis of that anomaly and the possible surgical implications following misdiagnosis of that anomaly.

Dilatation of the intrahepatic bile duct associated with congenital anomalous junction of the cystic duct--a new disease entity

We describe 3 children with dilatation of the intrahepatic bile duct, who had anomalous junctions of the cystic duct, 2 high and 1 low, without pancreaticobiliary maljunction. They were all male, and underwent excision of the gallbladder and the extrahepatic bile duct followed by a Roux-en-Y hepaticojejunostomy as a definitive surgery. Postoperatively, the dilated intrahepatic bile duct became normal in size. From these 3 cases, we propose a new disease entity-dilatation of the intrahepatic bile duct because of congenital anomalous junction of the cystic duct.

Low conjunction of the cystic duct with the common bile duct: does it correlate with the formation of common bile duct stones?

BACKGROUND

This study aimed to evaluate the accuracy of magnetic resonance cholangiography (MRC) in detecting variants of low cystic duct conjunction, which can be a source of confusion during surgery when unrecognized.

METHODS

All cases with both MRC and endoscopic retrograde cholangiography (ERC) indicating suspected common bile duct stones between January 1999 and January 2004 were retrospectively reviewed by investigators blinded to the final diagnosis. Assessment with ERC was regarded as the gold standard. The aim was to find a low conjunction of the cystic duct with the bile duct. The sensitivity and specificity of MRC were calculated in comparison with those for ERC. The cystic junction radial orientation was defined as lateral (insertion diagonally from the right), medial (insertion into the left side of the common hepatic duct), or posteroanterior (overlap of the junction with the bile duct in the posteroanterior view). A spiral cystic duct and a long parallel course were evaluated separately.

RESULTS

Low insertion of the cystic duct was found on ERC in 66 of 622 patients (11%; 28 men and 38 women; mean age, 64.5 years). The sensitivity and specificity of MRC for detecting low cystic entrance were 100% (90.4% on an intention-to-diagnose basis and 100%, respectively). In 11 patients (16.6%), the radial orientation of the cysticohepatic junction could not be defined with MRC. The rate of correct MRC delineation was 95% for lateral (n = 21), 77% for medial (n = 26), and 74% for posteroanterior (n = 19) insertion of the cystic duct.

CONCLUSION

The findings showed that MRC has good correlation with ERC with regard to the location and anatomic details of cystic duct insertion. Although this does not generate a separate indication for MRC before laparoscopic cholecystectomy, the anatomic information can be of additional use when MRC is clinically indicated in this setting.

Agenesis of the Gallbladder With Hypoplastic Cystic Duct Diagnosed at Laparoscopy

An 86-year-old man was admitted to our department with complaints of intermittent upper abdominal pain. Ultrasonography of the abdomen showed dilated extrahepatic bile ducts containing stones; however, the gallbladder was not clearly identified. Magnetic resonance cholangiopancreatography showed dilated extrahepatic ducts and choledocholithiasis without gallbladder visualization. The stone extraction was performed with endoscopic sphincterotomy. Three-dimensional images using spiral-computed tomography after intravenous-infusion cholangiography clearly demonstrated an obstruction of the cystic duct. The patient was scheduled for laparoscopic cholecystectomy. At laparoscopy, the gallbladder fossa was not identified on the undersurface of the liver. Despite a thorough examination of the intrahepatic (left-sided within the lesser omentum), retroperitoneal, retrohepatic (within the falciform ligament), retroduodenal, and retropancreatic areas using laparoscopic ultrasonography, the gallbladder was not found. After careful dissection of the hepatoduodenal ligament, the dilated extrahepatic bile duct and a 1-cm length of hypoplastic cystic duct were found. Gallbladder agenesis is usually accompanied by the lack of the cystic duct. The present case is the third report of gallbladder agenesis with a patent or hypoplastic cystic duct.

Spiral cystic duct: beware

Laparoscopic cholecystectomy (LC) is currently the most popular operation performed for gallbladder disease. Our objective is to emphasize the superiority of the "critical view technique" over the "infundibular technique" in case of inflammation or aberrant anatomy. We present a case of a 21-year-old female who was taken to the operating room for LC. The critical view technique was performed with anterolateral infundibular retraction, and the infundibulum and body were dissected along the peritoneal reflection on both sides of the gallbladder. The cystic duct and infundibulum were funnel shaped and spiraled from lateral to posteromedial rotation. Aberrant anatomy is commonly seen during LC. We have routinely espoused the critical view technique or the use of intraoperative cholangiogram and believe that it should be applied to aid in the identification of the cystuc duct (CD). We avoid the infundibular technique, because it may be a contributing factor to common bile duct (CBD) injury.

Right hepatic duct opening into the cystic duct: the role of pre- and intraoperative cholangiography

Although an aberrant hepatic duct entering the cystic duct is not especially rare, the main right hepatic duct entering the cystic duct is extremely rare. A 69-year-old woman developed severe intermittent right upper quadrant pain and high fever. A diagnosis of acute calculus cholecystitis was made by radiographic examinations. Magnetic resonance cholangiopancreatography demonstrated dilatation of the right hepatic duct, but could not identify the junction of the right hepatic duct and the cystic duct. Endoscopic retrograde cholangiopancreatography established that the right hepatic duct joined the cystic duct and that cholecystolithiasis was present. As the right hepatic duct entering the cystic duct can lead to ductal injury, this anomaly should be kept in mind when performing laparoscopic cholecystectomy. Pre- and intraoperative cholangiography contribute to the avoidance of iatrogenic bile duct injury. When the right hepatic duct drains into the cystic duct, the gallbladder should be removed distal to the junction of the hepatic and cystic ducts.

Cystic duct directly joining the main pancreatic duct

A unique anomaly of the direct union between the cystic duct and the main pancreatic duct is presented. A 19-year-old man with a history of repeated epigastralgia underwent endoscopic retrograde cholangiopancreaticography that showed a direct union between the cystic duct and the main pancreatic duct. No pancreaticobiliary maljunction was noticed. Cholecystectomy accompanied by resection of the long cystic duct was performed. The excised gallbladder showed cholesterolosis, chronic cholecystitis, and hyperplasia of the pseudopyloric glands microscopically. The patient has been well for 3 years since surgery.

Teratoma arising from anomalous common bile ducts: a case report

Teratoma arising from extrahepatic common ducts is very rare entity. The authors found 2 teratoma cases originating from common bile duct in the literature. As a third case, the authors report on a 4-month-old girl with benign cystic teratoma arising from distal common hepatic bile duct and with anomalous common bile ducts. Surgical management of the patient also is discussed.

Left-sided gallbladder associated with congenital hypoplasia of the left lobe of the liver: a case report and review of literature

Left-sided gallbladder is a rare anomaly that is often associated with other abnormal anatomy in the hepatobiliary system. We report our experience of a case of left-sided gallbladder associated with the congenital hypoplasia of the left lobe of the liver. A 71-year-old woman underwent cholecystectomy for acute cholecystitis. Intraoperative findings revealed the absence of the left lobe of the liver. The gallbladder was located in the left side of the round ligament, which was associated with abnormal intrahepatic portal branching. The incidence of left-sided gallbladder without situs inversus is very rare. The following anomalous anatomy associated with left-sided gallbladder should be a concern when a surgeon encounters a left-sided gallbladder: right-sided round ligament associated with abnormal intrahepatic portal branching and ectopic gallbladder attached to the left lobe of the liver that connects to the left hepatic duct via the cystic duct or the accessory bile duct.

Laparoscopic excision of a triple gallbladder

Triplication of the gallbladder is a rare congenital anomaly of the biliary tract; there are only nine reported cases to date. We report a case in which laparoscopic cholecystectomy was performed in a patient with biliary colic and choledocholithiasis. Preoperative assessment with ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) failed to reveal the eventual findings of a triple gallbladder. Successful excision of the triple gallbladder was carried out laparoscopically, and the final diagnosis was confirmed by the pathologist. The patient made an uneventful postoperative recovery and was free of gastrointestinal symptoms at follow-up. This case report describes the first laparoscopic excision of a triple gallbladder and highlights the importance of pre-/perioperative imaging to allow for the safe dissection of rare anomalies of the biliary tract via the laparoscopic approach.

[Congenital cystic dilatation of the cystic duct associated with an anomalous pancreaticobiliary ductal junction]

We report a case of congenital cystic dilatation of the cystic duct detected in a 40-year-old woman. She had intermittent pain in the right upper quadrant of the abdomen independent of the intake of meals for the last two years. In the ultrasound we found a cystic formation in the vicinity of the enlarged gallbladder, the common hepatic duct/common bile duct and the portal vein. The endoscopic retrograde cholangiography confirmed a cystic duct malformation, which was associated with an anomalous pancreaticobiliary ductal junction (APBDJ). A cholecystectomy with excision of the whole cystic duct and common bile duct and Roux-en-Y hepaticojejunostomy is indicated because there is an increased risk of the development of bile duct cancer and gallbladder cancer in the presence of biliary cystic duct anomalies and APBDJ.

Anomalous connection of the right hepatic duct into the cystic duct: utility of magnetic resonance cholangiopancreatography

A 41-year-old female was admitted to our hospital for treatment of uterus carcinoma. Abdominal ultrasound showed gallbladder stones. Although magnetic resonance cholangiopancreatography revealed the right intrahepatic bile ducts, left hepatic duct and the common bile duct, the confluence of the right and left hepatic ducts was not visualized. At surgery, intra-operative cholangiography showed a biliary anomaly of the right hepatic duct entering the cystic duct. Subsequently cholecystectomy was accomplished without any injury to the bile duct. Our case may be the eighth such case of this rare biliary anomaly. When magnetic resonance cholangiopancreatography does not show the confluence of the right and left hepatic ducts, biliary anomaly of the right hepatic duct should be suspected and careful dissection should be performed from the Hartman's pouch, followed by intraoperative cholangiography, in order to avoid unnecessary injury to the bile duct.

[Agenesis of the gallbladder]

The agenesis of the gall bladder is a rare congenital abnormality that usually is diagnosed as cholecystolithiasis. Therefore it is an intraoperative discovery. In this work two new cases are added to casuistry; both them have received laparotomic treatment. As those cases were symptomatic patients, the most common clinical manifestations are described. We insist in tactics to discard ectopic locations and the different options for the intraoperative and postoperative study; this last situation seems to be the most used behavior on patients approached laparoscopically.

Agenesis of the gallbladder and cystic duct

Agenesis of the gallbladder and cystic duct is a rare anomaly that is usually asymptomatic. The patient may present symptoms characteristic of cholelithiasis. Its surgical confirmation requires careful dissection of the common bile duct and intraoperative cholangiography or ultrasonography to be performed, to exclude the possibility of an ectopic gallbladder. The authors describe two cases of this unusual affection and comment on its clinical, pathophysiological and diagnostic aspects.

Role of intraoperative cholangiography in detecting rare bile duct anomalies

A case of an anomalous extrahepatic biliary system is reported in which the right hepatic duct was found to enter the infundibulum of the gallbladder. In this case, a selective intraoperative cholangiography has prevented a possible major iatrogenic injury.

Analysis of pathogenetic mechanisms of common bile duct iatrogenic lesion during laparoscopic cholecystectomy. A review of the literature

BACKGROUND

Laparoscopic cholecystectomy as the new gold standard for gallstone treatment has reopened the chapter of complications due to cholecystectomy.

METHODS

The present work refers to the period between 1988-2001 and analyses 277,121 cholecystectomies, carried out in some European and extra-European Countries. 1,353 CBD lesions with an incidence rate of 0.48%, that almost doubles that of the laparotomic cholecystectomies, were found. Transection of CBD within <2 cm of bifurcation was the most frequent lesion.

RESULTS

The mechanism and extension of CBD lesions is different when compared to that of laparotomic intervention. Actual damage is caused by a failure to recognise the anatomical structures, and also by errors in the surgical technique, learning curve and different visualisation of the operative field.

CONCLUSIONS

Once the lesion has been diagnosed it is always necessary to define its type and extension accurately. A therapeutic approach that fails to take this aspect into account will expose the patient to repeated and increasingly complex surgical interventions, recurrent cholangitis episodes and a higher risk of suffering a secondary biliary cirrhosis.

Isolated agenesis of the gallbladder: report of a case

We report the rare case of an isolated gallbladder with cystic duct agenesis that was misdiagnosed as acute alithiasic cholecystitis. We underline the inaccuracy of currently used diagnostic tests and the importance of making a correct preoperative diagnosis to avoid a needless surgical procedure. Based on the rare and incidental nature of this congenital anomaly, we discourage an extensive routine diagnostic workup, but rather, suggest a careful clinical and diagnostic evaluation of the patient who has symptoms suggestive of biliary tract disease. We conclude that in patients with gallbladder and cystic duct agenesis surgery might be useless and risky when performed by the laparoscopic approach. On the other hand, the awareness of the laparoscopic surgeon of the problems posed by this anomaly and a careful review of currently available diagnostic tests can prevent unnecessary laparotomy and minimize the risk of complications.

Congenital absence of the gallbladder and the cystic duct

A 47 years old female with congenital absence of the gallbladder and the cystic duct was presented. The diagnosis was confirmed by exploratory laparatomy, common duct tube cholangiography, and ultrasonography. Most of the operated cases of congenital absence of the gallbladder are symptomatic, and they get relief after common duct exploration. Although the biliary tree is normal on inspection at exploration, it is believed that the symptomatology may have root in congenital abnormality of function. Treatment of the agenesis of the gallbladder as described in earlier days has been discussed. In the present situation, specially in a country like Ethiopia where long time care of internal drains is a worrisome problem, and a major point for concern, the author believes choledocho-enteric anastomosis to be a good solution.

Absence of the common bile duct and junction of the cystic duct with the left hepatic duct in a patient with chronic portal vein thrombosis

A50-year-old male patient was admitted to the hospital because of fatigue and a palpable abdominal mass. The diagnoses of chronic renal failure and portal vein thrombosis were established by specific investigations. Incidentally, junction of the cystic duct with the left hepatic duct and absence of the common bile duct were found during endoscopic retrograde cholangiopancreatography study. To the authors' knowledge, this is the first reported case of an absence of the common bile duct and junction of the cystic duct with the left hepatic duct in a patient with chronic portal vein thrombosis. Such lesions may cause unexpected complications during biliary surgery.

MR imaging of the gallbladder

T2-weighted imaging and MRCP, which have high sensitivity to edema and fluid, are paramount in the evaluation of certain gallbladder diseases, such as cholelithiasis, cholecystitis, adenomyomatosis, and cystic duct abnormalities. Dynamic gadolinium-enhanced MR imaging has the potential to differentiate among the many nonspecific-appearing lesions involving the gallbladder. MR imaging may not yet replace ultrasound as the workhorse of acute gallbladder imaging. Currently, MRCP is an ideal complementary study to inconclusive sonographic studies and can help plan surgical intervention in the setting of acute cholecystitis. Further investigation of hepatobiliary contrast agents, however, may reveal that MR imaging may be considered as first-line imaging in the acute setting.