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 ¤ Introduction
 ¤ Case Report
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UNUSUAL CASE
Year : 2020  |  Volume : 16  |  Issue : 1  |  Page : 74-76
 

Magnetic resonance imaging-guided three-dimensional real-time bile duct reconstruction and end-to-end anastomosis under laparoscopy: A case report


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 Submission20-Sep-2018
Date of Acceptance01-Nov-2018
Date of Web Publication20-Dec-2019

Correspondence Address:
Dr. Zheng Siming
Department of Hepato-Biliary-Pancreatic Surgery, Ningbo Medical Centre of Lihuili Eastern Hospital, Ningbo 315040
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_242_18

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 ¤ Abstract 

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 Top


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 Top


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 Top


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 Top

1.
Mhatre S, Wang Z, Nagrani R, Badwe R, Chiplunkar S, Mittal B, et al. Common genetic variation and risk of gallbladder cancer in India: A case-control genome-wide association study. Lancet Oncol 2017;18:535-44.  Back to cited text no. 1
    
2.
Björnsson ES, Jonasson JG. Idiosyncratic drug-induced liver injury associated with bile duct loss and vanishing bile duct syndrome: Rare but has severe consequences. Hepatology 2017;65:1091-3.  Back to cited text no. 2
    
3.
Kohn JF, Trenk A, Kuchta K, Lapin B, Denham W, Linn JG, et al. Characterization of common bile duct injury after laparoscopic cholecystectomy in a high-volume hospital system. Surg Endosc 2018; 32:1184-91.  Back to cited text no. 3
    
4.
Reid J, Dolan R, Patel M, Fleming R, Young D, Hair A, et al. Size of common bile duct stones on MRCP predicts likelihood of positive findings at ERCP. Surgeon 2017;15:119-22.  Back to cited text no. 4
    
5.
Ejaz A, Spolverato G, Kim Y, Dodson R, Sicklick JK, Pitt HA, et al. Long-term health-related quality of life after iatrogenic bile duct injury repair. J Am Coll Surg 2014;219:923-32.e10.  Back to cited text no. 5
    
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.  Back to cited text no. 6
    
7.
Kohneh Shahri N, Lasnier C, Paineau J. Bile duct injuries at laparoscopic cholecystectomy: Early repair results. Ann Chir 2005;130:218-23.  Back to cited text no. 7
    
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.  Back to cited text no. 8
    
9.
Dominguez-Rosado I, Sanford DE, Liu J, Hawkins WG, Mercado MA. Timing of surgical repair after bile duct injury impacts postoperative complications but not anastomotic patency. Ann Surg 2016;264:544-53.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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