|Year : 2019 | Volume
| Issue : 2 | Page : 158-160
Laparoscopic evaluation and resection of type-II choledochal cyst arising from right hepatic duct mimicking gall bladder duplication
Rajesh Bhojwani, Nikhil Jain, Subhash Mishra
Department of Surgical Gastroenterology, Santokba Institute of Digestive Surgical Sciences, Santokba Durlabhji Memorial Hospital Cum Research Institute, Jaipur, Rajasthan, India
|Date of Submission||29-Apr-2018|
|Date of Acceptance||21-Jul-2018|
|Date of Web Publication||12-Mar-2019|
Dr. Rajesh Bhojwani
Santokba Institute of Digestive Surgical Sciences, Santokba Durlabhji Memorial Hospital Cum Research Institute, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
A Type II choledochal cyst arising from the right hepatic duct may mimic a gall bladder duplication. Both are rare and may not get differentiated before operative exploration. While a magnetic resonance cholangiopancreatography (MRCP) may be helpful, laparoscopy may be the final tool for evaluation and effective surgical treatment. We report such a case of a 22-year-old male whose MRCP was suggestive of a cystic lesion in the gall bladder fossa and was taken up for surgery with a pre-operative diagnosis of gall bladder duplication with a single cystic duct. He underwent elective laparoscopic evaluation, mobilisation, discerning of anatomy and diagnosis, excision of cyst and concomitant cholecystectomy. This case highlights that these two rare entities can mimic each other on imaging; however, a laparoscopic approach serves the dual purpose of diagnosing and treating this unique pathoanatomical entity.
Keywords: Biliary anomalies, choledochal cyst, gall bladder duplication, laparoscopic, surgery
|How to cite this article:|
Bhojwani R, Jain N, Mishra S. Laparoscopic evaluation and resection of type-II choledochal cyst arising from right hepatic duct mimicking gall bladder duplication. J Min Access Surg 2019;15:158-60
|How to cite this URL:|
Bhojwani R, Jain N, Mishra S. Laparoscopic evaluation and resection of type-II choledochal cyst arising from right hepatic duct mimicking gall bladder duplication. J Min Access Surg [serial online] 2019 [cited 2019 Jun 26];15:158-60. Available from: http://www.journalofmas.com/text.asp?2019/15/2/158/240456
| ¤ Introduction|| |
Choledochal cysts are rare and type II choledochal cysts are particularly uncommon. A type ii choledochal cyst arising from the right hepatic duct projecting into the gall bladder fossa and presenting as a gall bladder duplication on imaging has not been reported earlier. Laparoscopy serves as a final tool for diagnosis and conclusive treatment.
| ¤ Case Report|| |
A 22-year-old male presented with complaints of intermittent upper abdominal dull aching pain associated with nausea and vomiting for 1 year, but no history of jaundice or fever. Physical examination showed no abnormality. Ultrasound of the abdomen showed a cystic lesion near the neck of gall bladder. Magnetic resonance cholangiopancreatography (MRCP) showed a cystic lesion of 1.5 cm × 1.2 cm at the porta closely abutting the neck region of the gall bladder, cystic duct and adjacent right posterior hepatic duct with a suspicious suggestion of communication with the cystic duct [Figure 1]. The patient was taken up for surgery with a pre-operative diagnosis of gall bladder duplication. The ports were placed in a standard configuration for laparoscopic cholecystectomy. Using the fundus first approach, the gall bladder was dissected off revealing a cystic lesion approximately 3 cm × 3 cm closely adherent to the right hepatic artery and right hepatic duct. The Calot's triangle had a normal anatomy with a single cystic duct inserting into the common bile duct. The cystic lesion was connected to the right hepatic duct with a thin fibrous stalk [Figure 2]. The patient underwent elective laparoscopic evaluation, mobilisation, discerning of anatomy and diagnosis, excision of cyst and concomitant cholecystectomy. He had an uneventful post-operative recovery. Histopathology confirmed the cyst as a bile duct cyst, and the gall bladder showed features of chronic cholecystitis.
|Figure 1: Magnetic resonance cholangiopancreatography showing a cystic lesion at the porta closely abutting the neck of gall bladder, cystic duct and right posterior hepatic duct with faint suspicious communication of the lesion with cystic duct. C: Cyst. GB: Gall bladder. CBD: Common bile duct. RHD: Right hepatic duct|
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|Figure 2: Intraoperative pictures in sequence depicting the procedure. (a) The gall bladder is grasped showing the cyst in relation to the gall bladder and cystic duct. (b) The gall bladder has been dissected in a fundus first manner. (c) The cyst has been dissected from the liver bed. (d) After dissecting the cyst has been defined in relation to the right hepatic duct and the connecting thin stalk has been clipped before dividing. CD: Cystc duct. CBD: Common bile duct. GB: Gall bladder. C: Cyst|
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| ¤ Discussion|| |
Choledochal cysts are rare congenital cystic dilatations of the biliary tree with a male: female ratio of 1:3–1:8 with up to 74% of all patients now reported being adults. Type II choledochal cyst is rare with an incidence of 3%. Ouaïssi et al. classified the type II cysts according to the location in relation to the hepatoduodenal ligament as upper, middle and lower with reported incidence as 58%, 21% and 21%, respectively. Duplication of the gall bladder has an incidence of approximately 1:4000 occurring nearly twice in women than in men. The differential diagnosis includes gall bladder diverticula, gall bladder fold, Phrygian cap, choledochal cyst, pericholecystic fluid, focal adenomyomatosis and intraperitoneal fibrous bands.
Histologically, gall bladder duplication is differentiated from a choledochal cyst by the presence of a muscular wall with an epithelial lining. MRCP has evolved as the current gold standard for diagnosis of choledochal cysts with the distinct advantage of being non-invasive in nature. The younger age of occurrence of carcinoma in patients with bile duct cysts forms the basis of surgical resection. Type-II choledochal cyst is uncommon, and so is the duplication of gall bladder. A type-II choledochal cyst arising from the intrahepatic bile duct with a very tiny communication is further rare. An extensive search on the available medical databases did not reveal such a pathoanatomical entity being reported earlier. The pre-operative workup in the form of MRCP does not differentiate between the two. An invasive investigation in the form of endoscopic retrograde cholangiopancreatography may not be indicated to avoid the potential complications involved. Laparoscopy seems very well in terms of evaluation of the anatomy, discerning and defining the final diagnosis and serving the treatment in the form of resection at the same. The final diagnosis was settled by the histopathology. When treated with simple cyst excision, a procedure which can be performed laparoscopically, the defect in the wall of the common bile duct should be closed in a transverse manner rather than longitudinal to minimise the possibility of narrowing the lumen of the common bile duct.
| ¤ Conclusion|| |
While pre-operative workup may not suggest the existence of a type-II choledochal cyst in the gall bladder bed, meticulous laparoscopic dissection serves well to define the anatomy and provide the treatment in terms of resection at the same time. A type-II choledochal cyst arising from the right hepatic duct though rare should be considered in the differential diagnosis of duplication of gall bladder particularly when only one cystic duct is seen.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]