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  ¤  Case Report
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 Table of Contents     
UNUSUAL CASE
Year : 2019  |  Volume : 15  |  Issue : 3  |  Page : 256-258
 

High insertion of cystic duct at the gallbladder fundus: An undescribed anomaly!


Department of General Surgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India

Date of Submission07-Aug-2018
Date of Acceptance01-Oct-2018
Date of Web Publication4-Jun-2019

Correspondence Address:
Gabriel Rodrigues
Kasturba Medical College, Manipal Academy of Higher Education, Manipal - 576 104, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_199_18

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 ¤ Abstract 

The anatomy of the biliary tree is complex, and its variations of both intra- and extra-hepatic bile ducts can be found in approximately 30% of the general population. These variations are not picked up on routine pre-operative investigations of patients planned for a laparoscopic cholecystectomy (LC) and often present as an unusual 'surprise' and a challenge that can make dissection in the Calot's triangle difficult leading to iatrogenic injury. We present a case of a 53-year-old female with an undescribed anomaly encountered during an LC. There was a high insertion of the cystic duct into the fundus of the gallbladder. No such anomaly has been described in literature till date.


Keywords: Anatomy, Calot's triangle, cholecystectomy, cystic duct, laparoscopy


How to cite this article:
Rodrigues G, Pandit SR, Khan A, Veerabharappa B, Jayasankar B, Anaparti R. High insertion of cystic duct at the gallbladder fundus: An undescribed anomaly!. J Min Access Surg 2019;15:256-8

How to cite this URL:
Rodrigues G, Pandit SR, Khan A, Veerabharappa B, Jayasankar B, Anaparti R. High insertion of cystic duct at the gallbladder fundus: An undescribed anomaly!. J Min Access Surg [serial online] 2019 [cited 2019 Dec 13];15:256-8. Available from: http://www.journalofmas.com/text.asp?2019/15/3/256/245147



 ¤ Introduction Top


Anatomical variations of the biliary tree occur in approximately 30% of general population and are the most common cause of iatrogenic bile duct injury during a laparoscopic cholecystectomy (LC).[1] Ultrasonogram (USG) of the abdomen is the routinely done radiological investigation for a patient presenting with symptomatic gallstone disease and cannot routinely pick up the subtle anatomical variations of the biliary tree. Hence, these variations are commonly encountered as a surprise during a laparoscopic surgery.[2]

Several variations of the cystic duct anatomy have been described: cystic duct insertion into the right hepatic duct, anterior or posterior spiral insertion of cystic duct and the presence of a very long or short cystic duct.[3] However, in all these anomalies the insertion of the cystic duct onto the neck of gallbladder (GB) has always been constant. In this case report, we describe a cystic duct arising from the common bile duct (CBD), but ending in the GB fundus, an anomaly that has been never described in literature so far.


 ¤ Case Report Top


A 53-year-old female with no comorbidities presented with a 4-month history of intermittent colicky right hypochondriac (RHC) pain, exaggerated on consuming fatty foods and was occasionally associated with non-bilious, non-blood-stained vomiting. There was no other positive history. General examination was unremarkable and per abdominal examination revealed mild tenderness in the RHC with no palpable mass. Routine laboratory investigations including liver function tests (LFT) was normal. An USG of the abdomen showed chronic calculous cholecystitis with a normal CBD. She was posted for an LC. On dissection of the Calot's triangle, the cystic artery was identified and clipped. However, the cystic duct could not be identified. The Hartmann's pouch and infundibulum were completely dissected out of the Calot's triangle. There was no bile leak during dissection. A tubular structure was seen on the under surface of the liver (GB fossa) traversing upwards and inserting into the GB fundus, where it thinned out [Figure 1]. This structure was identified to be the cystic duct and was clipped near the fundus after complete posterior dissection of the GB out of the liver bed [Figure 2]. Due to the doubtful anatomy of the cystic duct, the surgery was converted to open. A long cystic duct was identified arising from the CBD and travelling upwards on the under surface of the liver for approximately 6 cm before inserting onto the fundus of the GB. This long cystic duct was ligated close to the CBD. A drain was placed in the GB bed, and the incision was closed in layers.
Figure 1: Cystic duct traversing up towards the gall bladder fundus (arrow)

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Figure 2: (a) Cystic duct thinned out and entering the gall bladder fundus (arrow); (b) cystic duct clipped

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Postoperatively, she made an uneventful recovery, and the abdominal drain was clear with no bile. LFT repeated on post-operative day 3 was normal. She was discharged after the drain removal and at the end of 3 months is doing well.


 ¤ Discussion Top


A classical anatomy of the biliary tree is present only in 30% of individuals; thus, it may be quoted that anomalies are the rule.[1] A thorough knowledge of the normal anatomy and its variants is important for successful surgical intervention. The most common anomaly causing problems during an LC is an aberrant right hepatic duct. The most dangerous anomaly is when the cystic duct joins a low lying aberrant right posterior sectoral duct.[2]

A retrospective study done over a period of 3 years in Turkey on 590 patients who underwent magnetic resonance cholangiopancreatography (MRCP) identified 39.5% of patients with biliary tract variations with a total of 275 types of variations.[3] In a similar retrospective study done in Italy between 2004 and 2007 on 350 patients undergoing MRCP for various indications, anatomical variations were found in 42.3% of patients of which 8.8% were anomalies of the cystic duct.[4] The most common anomaly of the cystic duct was its low insertion into the right hepatic duct.[2] In all the above studies among the numerous anatomical variations picked up, none have described a high insertion of cystic duct at the GB fundus, that occurred in our patient.

Pre-operative baseline investigations done before LC will never pick up extra-hepatic biliary ductal abnormalities and are often found as a 'surprise'. It is important to clearly identify the structures within the Calot's triangle to prevent iatrogenic injury to the bile or hepatic ducts, which contribute to the morbidity and mortality.[5] In such patients, intraoperative cholangiography (IOC) helps to delineate biliary tree anatomy, prevent bile duct injury and image stones in the CBD, although the routine use of IOC in LC remains a contentious issue.[6] The anomaly presented in the above case report has not been described previously in literature. The need of knowing and understanding of the anatomical variations of the extrahepatic biliary tree cannot be under-stressed!

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her 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

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 ¤ References Top

1.
Prasanna LC, D'Souza AS, Rajagopal KV, Bhat KM. A study on the human pancreaticobiliary duct system and ampulla region with their clinical considerations. Indian J Gastroenterol 2015;34:58-62.  Back to cited text no. 1
    
2.
Gupta A, Rai P, Singh V, Gupta RK, Saraswat VA. Intrahepatic biliary duct branching patterns, cystic duct anomalies, and pancreas divisum in a tertiary referral center: A magnetic resonance cholangiopancreaticographic study. Indian J Gastroenterol 2016;35:379-84.  Back to cited text no. 2
    
3.
Onder H, Ozdemir MS, Tekbaş G, Ekici F, Gümüş H, Bilici A, et al. 3-T MRI of the biliary tract variations. Surg Radiol Anat 2013;35:161-7.  Back to cited text no. 3
    
4.
De Filippo M, Calabrese M, Quinto S, Rastelli A, Bertellini A, Martora R, et al. Congenital anomalies and variations of the bile and pancreatic ducts: Magnetic resonance cholangiopancreatography findings, epidemiology and clinical significance. Radiol Med 2008;113:841-59.  Back to cited text no. 4
    
5.
Hasan MM, Reza E, Khan MR, Laila SZ, Rahman F, Mamun MH, et al. Anatomical and congenital anomalies of extra hepatic biliary system encountered during cholecystectomy. Mymensingh Med J 2013;22:20-6.  Back to cited text no. 5
    
6.
Verma S, Wichmann MW, Gunning T, Beukes E, Maddern G. Intraoperative cholangiogram during laparoscopic cholecystectomy: A clinical trial in rural setting. Aust J Rural Health 2016;24:415-21.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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