Laparoscopic cholecystectomy is currently regarded as the standard surgical treatment for cholecystitis and cholecystolithiasis. Bile duct injury continues to be a serious complication of laparoscopic cholecystectomy [1] and occasionally stems from the presence of unrecognized variants of the anatomical biliary tree [2, 3]. Anatomical variants of the biliary tree include aberrant right hepatic duct (ARHD), which has an incidence of approximately 5% (1.02–35%) [4]. An ARHD drains primarily into the common hepatic duct, common bile duct, or left hepatic duct. Notably, an ARHD rarely flows into the cystic duct, and this anatomical variant occasionally accounts for an injured ARHD during surgery [5]. A rare occurrence of ARHD draining into the cystic duct requires meticulous care during cholecystectomy, as injury can prompt postoperative bile leakage and postsurgical complications. The Critical View of Safety (CVS) technique first introduced by Strasberg is based on the precise anatomical assessment and identification of biliary tree variants [1, 5] and can prevent accidental biliary and vascular injuries due to uncommon anatomical variations [1, 6].
Magnetic resonance cholangiopancreatography (MRCP) was recently reported to be an optimal imaging modality that can provide biliary tract information and accurately distinguish the presence of biliary tree variants [7]. The case presented here reports the successful application of laparoscopic cholecystectomy supported by preoperative MRCP in the management of an ARHD draining into the cystic duct of a patient with chronic cholecystitis.
Case presentation
A 49-year-old male with a history of cholelithiasis presenting with right hypochondoralgia with a positive Murphy’s sign was referred to our department for surgical treatment. Computed tomography (CT) without contrast media revealed a gallstone in the thickened gallbladder wall with a slight increase in the CT value due to surrounding panniculitis (Fig. 1). MRCP revealed that the cystic duct branched from the common bile duct and an aberrant bile duct connected to the cystic duct (Fig. 2, yellow arrow). The link between the aberrant bile duct and major intrahepatic biliary system was not visually apparent by MRCP. The patient was diagnosed with chronic calculous cholecystitis with aberrant bile duct flow into the cystic duct. During laparoscopic cholecystectomy, four ports were placed: a 12-mm camera port in the umbilical area by open method, 12-mm port in the epigastric area, 5-mm port in the right subcostal area, and a 5-mm port at the right lateral abdomen. Due to inflammatory fibrotic adhesion in Calot’s triangle, the ARHD was excessively exposed. A fundus-first technique was performed to confirm the ARHD after exposure of the inner layer of the subserosal layer at the dorsal and ventral side of Calot’s triangle. ARHD drainage into the cystic duct was confirmed. Preoperative MRCP suggested it was not necessary to preserve the ARHD with the extreme narrow drainage area as it seemed to be closed at the hepatic side without communicating with the major right branch of the intrahepatic bile duct.
Intraoperative cholangiography from the cystic duct in the periphery (Fig. 3) revealed that the ARHD was not confluent with the major right branch of the intrahepatic bile duct and drained a narrow area, so we removed the excessively exposed ARHD. Removal and ligation of the ARHD on the hepatic side and cystic duct was performed by clipping (AESCULAP DS Titanium Ligation Clips, B Braun brand, Tokyo, Japan). An absence of bile leakage precluded any placement of drainage. The surgical movie is available online only (Additional file 1: Video). The postoperative course was uneventful, and the patient was discharged on the third postoperative day. Follow-up MRCP showed no dilated bile duct in the liver 1 month after surgery (Fig. 4). The resected specimen was diagnosed as chronic cholecystitis. Laboratory analysis showed no abnormal increase in AST, ALT, ALP, or bilirubin 1 month after surgery (data not shown), and no abnormal symptoms 3 months after surgery. Then, his family doctor is currently following up him.
Additional file 1: Video Summary video of the surgery (MP4 17983 kb)
