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UNUSUAL CASE |
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| Year : 2020 | Volume
: 16
| Issue : 1 | Page : 74-76 |
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Magnetic resonance imaging-guided three-dimensional real-time bile duct reconstruction and end-to-end anastomosis under laparoscopy: A case report
Zhu Jie1, Zheng Siming2, Zhang Xuechang3, Wang Xiancheng3
1 Department of Hepato-Biliary-Pancreatic Surgery, Ningbo Medical Centre of Lihuili Hospital, Ningbo, China
2 Department of Hepato-Biliary-Pancreatic Surgery, Ningbo Medical Centre of Lihuili Eastern Hospital; Department of Mechanical and Energy Engineering, Zhejiang University Ningbo Institute of Technology, Ningbo, China
3 Department of Hepato-Biliary-Pancreatic Surgery, Taipei Medical University Ningbo Medical Centre, Ningbo, China
| Date of Submission | 20-Sep-2018 |
| Date of Acceptance | 01-Nov-2018 |
| Date of Web Publication | 20-Dec-2019 |
Correspondence Address:
Dr. Zheng Siming
Department of Hepato-Biliary-Pancreatic Surgery, Ningbo Medical Centre of Lihuili Eastern Hospital, Ningbo 315040
China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmas.JMAS_242_18
In laparoscopic cholecystectomy (LC), the anatomical variation of gallbladder canal should be noted. Bile duct injury is one of the most serious complications of LC, which might lead to serious complications. This case because of an intraoperative accidental cut to right anterior inferior lobe bile duct which joins to the cystic duct, after confirming by intraoperative magnetic resonance imaging-guided real-time three-dimensional bile duct reconstruction and performing end-to-end anastomosis of the right anterior inferior lobe bile duct and the gallbladder tube under laparoscopy, the patient was discharged 5 days after surgery, was followed up for 4 months and was disease-free.
Keywords: Anastomosis, biliary variation, end to end, laparoscopy, three-dimensional
How to cite this article:
Jie Z, Siming Z, Xuechang Z, Xiancheng W. Magnetic resonance imaging-guided three-dimensional real-time bile duct reconstruction and end-to-end anastomosis under laparoscopy: A case report. J Min Access Surg 2020;16:74-6 |
How to cite this URL:
Jie Z, Siming Z, Xuechang Z, Xiancheng W. Magnetic resonance imaging-guided three-dimensional real-time bile duct reconstruction and end-to-end anastomosis under laparoscopy: A case report. J Min Access Surg [serial online] 2020 [cited 2020 Oct 28];16:74-6. Available from: https://www.journalofmas.com/text.asp?2020/16/1/74/249450 |
| ¤ Introduction | |  |
Since the rapid development and popularisation of laparoscopic cholecystectomy (LC) techniques, it has been accompanied with bile duct injury (BDI). The incidence of BDI is higher than that of the open abdominal gallbladder, which has been 0.1%–0.2% goes up to 0.4%–1.0%, even higher. Whether it is an open cholecystectomy or LC, IBD is still a worrying clinical problem. The mutation of the gallbladder canal increases the difficulty of surgery and increases the risk of an iatrogenic BDI. In this case, we accidentally cut the right anterior inferior lobe bile duct which is joined to the cystic duct, after confirming by intraoperative magnetic resonance imaging (MRI)-guided real-time three-dimensional (3D) bile duct reconstruction; we thought that duct might play an important role, and hence, we performed end-to-end anastomosis by a 5-0 absorbable suture under laparoscopy.
| ¤ Case Report | | |
A 37-year-old male patient, without any history of trauma or important previous symptoms, was admitted to the hepatobiliary surgery clinic in August 2017 with the complaint of abdominal pain after eating fatty foods. Physical examination revealed signs of pain of right epigastric abdomen without Murphy's sign. Laboratory tests were normal. Chest and abdominal X-ray revealed no free air in the abdomen. An ultrasound examination and MRI revealed gallbladder stone while common bile duct stone was not reported. The extrahepatic biliary variation [Figure 1] which was showed on MRI was ignored by us carelessly until we made a mistake. | Figure 1: Magnetic resonance imaging examination. (a) Extrahepatic biliary variation of the right anterior inferior lobe bile duct which joining to the cystic duct; (b) magnetic resonance imaging reexamination after 4 months
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Because of these findings, the patient underwent three ports LC. When the cystic duct was separated, we completely divided an unknown bile duct which might be very important to the hepatic. Hence, we decided to undergo MRI-guided real-time 3D bile duct reconstruction during the operation and totally took 30 min [Figure 2]. 3D figures showed that the unknown bile duct was the right anterior inferior lobe bile duct which joins to the cystic duct, and it was the only passage to drain the choler from that lobe of the liver. Hence, we decided to perform bile duct end-to-end anastomosis [Figure 3]. A drainage tube was placed at the stoma. The patient was discharged after 5 days when the drainage tube was removed and was followed up 4 months and got MRI reexamination and 3D reconstruction. | Figure 2: Intraoperative photograph. (a) Bile duct end-to-end anastomosis; (b) bile duct end-to-end anastomosis was completed
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 | Figure 3: Magnetic resonance imaging-guided real-time three-dimensional bile duct reconstruction. (a) Extrahepatic biliary variation of the right anterior inferior lobe bile duct which joining to the cystic duct; (b) three-dimensional bile duct reconstruction after 4 months
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| ¤ Discussion | | |
LC has become classic minimally invasive surgical techniques and gradually replaced open surgery as the preferred treatment for symptomatic gallbladder stone. In LC, it should be noted that the variation of gallbladder tube is accounting for 18%–23%.[1] Improper traction in the operation, difficulty and unawareness in identifying the structure of the bile duct by the surgeon and the complexity of the dissection often lead to the occurrence of BDI. BDI is one of the most serious complications of LC, which might cause bile leakage, bile duct stricture, obstructive jaundice and other serious complications, not only increased the hospitalisation expenses but also endangering the patient's life.[2] Since there existence of the cholecystectomy operation, it has been accompanied by IBDI, especially with the rapid development and popularity of LC nowadays. The incidence of BDI is higher than open cholecystectomy, which is already 0.1%–0.2% goes up to 0.4%–1.0%, even higher.[3]
Therefore, the prevention of biliary injury and the timely treatment of biliary injury are both important to patients. MR cholangiopancreatography (MRCP) examination can effectively detect intrahepatic bile duct variation, which can be an important examination method for complex bile duct stones.[4] Ruiz Gomez F etc., strongly recommended that routine intraoperative cholangiography needed to be considered, they thought that intraoperative biliary imaging examination is high sensitivity and specificity which had high value of finding intraoperative BDI and little damage to patients.[5] For some reasons, we did not make the intraoperative cholangiography. When we carefully reviewed the pre-operative MRCP and MRI examination, we vaguely thought that there was variation in the bile duct; at the same time, we could not make a good judgement of which liver segment was under the control of that bile duct. We have a rich experience of 3D reconstruction on MRI and computed tomography (CT), so we temporarily tried to conduct 3D reconstruction on MRI of the biliary tract using 3D reconstruction software. The 3D reconstruction of bile duct in this case confirmed that the right anterior inferior lobe bile which governs the right anterior inferior lobe of the liver duct that flows into the gallbladder canal was divided by us. We found that this technique appeared to be superior to cholangiography and MRCP, which were faster, easier for experienced engineers to operate, and it could show the liver parenchymal and further help us judging which bile duct was injured and that it governs its liver lobe, depending on which we could decide whether to perform anastomosis to the injure bile duct, if the liver lobe was very important. We believe that MRI or CT-guided real-time bile duct 3D reconstruction as a non-invasive method can clearly show the bile duct structure and discover its variation. In our hospital, all the LC patients received MRI or CT examination pre-operatively; however, not every LC needs to conduct 3D reconstruction of the bile duct, only after the occurrence of BDI or if the surgery might be a challenging for surgeons.
If the thicker accessory hepatic duct was ligated, it might cause cholestasis, the proliferation of bacteria, the recurrence of cholangitis and even the hepatic abscess. Bile duct end-to-end anastomosis can maintain the original physiological structure of the biliary system avoid biliary tract ischemia which might cause post-operative bile leakage and bile duct stricture.[6] A prospective non-randomised study of Kohneh Shahri et al. confirmed that the prognosis of bile duct anastomosis was significantly higher than that of cholangiojejunostomy.[7] de Reuver et al. recommended that the first time of repair should consider the bile duct to the end anastomosis if there is no extensive tissue loss during perioperative period.[8] When performing LC, if the technical conditions are allowed, it should be repaired by laparoscopic surgery, otherwise convert to open surgery immediately.[9] In this case, we performed the bile duct end-to-end anastomosis under laparoscopy, the posterior wall first and then the anterior wall was continuously sutured using a 5-0 absorbable suture.
The BDI occurs in both open cholecystectomy and LC. The application of laparoscopic minimally invasive technique can achieve accurate end-to-end anastomosis, little injury, small impact on the whole body, fewer complications and which has opened up a new road for biliary injury repair. Laparoscopic repair of a damaged bile duct is technically demanding, and the application of MRI or CT-guided 3D bile duct reconstruction has little number of clinical cases, which needs big sample of randomised controlled trial in the future.
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
- Scientific Innovation Team Project of Ningbo (2013B82010)
- Natural Science Foundation of Zhejiang Province, China, under Grant Nos. LY17E050011
- Research project on key technologies of complex surgery for liver resection based on 3D printing, Ningbo, China. Grant Nos. 2015C50025
- Ningbo Health Branding Subject Fund (PPXK2018-03).
Conflicts of interest
There are no conflicts of interest.
| ¤ References | | |
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| 6. | Zhang X, Tian Y, Xu Z, Wang L, Hou C, Ling X, et al. Healing process of the guinea pig common bile duct after end-to-end anastomosis: Pathological evaluation after 6 months. Eur Surg Res 2011;46:194-206. |
| 7. | Kohneh Shahri N, Lasnier C, Paineau J. Bile duct injuries at laparoscopic cholecystectomy: Early repair results. Ann Chir 2005;130:218-23. |
| 8. | de Reuver PR, Busch OR, Rauws EA, Lameris JS, van Gulik TM, Gouma DJ, et al. Long-term results of a primary end-to-end anastomosis in peroperative detected bile duct injury. J Gastrointest Surg 2007;11:296-302. |
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[Figure 1], [Figure 2], [Figure 3]
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