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Luitel P, Paudel S, Thapaliya I, Dhungana S, Thapa N, Devkota S. Bile duct injury following laparoscopic cholecystectomy in a patient with a trifurcated hepatic duct: A case report. Int J Surg Case Rep 2024; 123:110145. [PMID: 39241475 PMCID: PMC11408799 DOI: 10.1016/j.ijscr.2024.110145] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 08/01/2024] [Accepted: 08/08/2024] [Indexed: 09/09/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Iatrogenic bile duct injury is a serious complication of laparoscopic cholecystectomy, often due to misinterpretation of biliary tree anatomy. Anatomical variations, patient condition, gallbladder pathology, and surgeon-related factors are key risk factors for bile duct injury. CASE PRESENTATION A 68-year-old male with a history of hypertension and type 2 diabetes mellitus underwent Laparoscopic cholecystectomy for symptomatic gallstones. One-month post-surgery, he developed right upper quadrant pain, jaundice, and elevated liver enzymes. Magnetic resonance cholangiopancreatography (MRCP) showed a hilar confluence stricture affecting the right posterior and left hepatic ducts, with mild-to-moderate dilation of upstream intrahepatic bile ducts. CLINICAL DISCUSSION Trifurcation of the hepatic duct is a rare but clinically significant anatomical variation that can predispose patients to common bile duct injuries. Preoperative MRCP can identify such variations, aiding in surgical planning. However, intraoperative recognition and management of these anatomical differences are crucial to prevent bile duct injuries. This is particularly important in low-resource settings where routine preoperative imaging may not be feasible. CONCLUSION Accurate intraoperative identification of biliary tree anatomical variations is essential to prevent iatrogenic injuries during surgery. Preoperative imaging, when available, can provide valuable information to assist in surgical planning. Additionally, the use of intra-operative cholangiogram (IOC) should be considered to help identify and manage anatomical variations, thereby reducing the risk of bile duct injuries.
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Affiliation(s)
- Prajjwol Luitel
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Sujan Paudel
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Ishwor Thapaliya
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.
| | - Shrawan Dhungana
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | | | - Shishir Devkota
- Department of General Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
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Olmedo NB, Dos Santos JS, Junior JE. The Frequency of Anatomical Variants of the Bile Ducts: A Review Based on a Single Classification as Support for Cholangiographic Examinations. Cureus 2024; 16:e58905. [PMID: 38800324 PMCID: PMC11118781 DOI: 10.7759/cureus.58905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/29/2024] Open
Abstract
Complications arising from hepatobiliary surgery can have adverse effects on both the quality of life and the survival of patients. Magnetic resonance cholangiography (MRC) techniques are highly effective at revealing anatomical variants of the bile ducts and thus play a vital role in minimizing the occurrence of complications. The aims of this review are threefold: to ascertain the classifications utilized for categorizing anatomical variants of the bile ducts, to present the reported results on the prevalence of these anatomical variants, and to explore the diagnostic modalities employed to visualize these anatomical variants and associated complications during surgical procedures. A review of the literature was carried out using the Cochrane Library database and the PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), and Google Scholar platforms. We conducted a comprehensive review of relevant studies to categorize the different anatomical variants according to the Huang classification. According to the Huang classification, our study showed type A1, 60.44%; type A2, 11.76%; type A3, 11.73%; type A4, 5.47%; type A5, 0.26%; and type B, which was identified in insignificant numbers (0.16%) or does not appear; additionally, variants that do not fit into the Huang classification have also been identified (10.18%). The Huang classification serves as an invaluable presurgical guide, aiding in the strategic planning of biliary interventions and effectively reducing the risk of iatrogenic complications, morbidity, mortality, and postoperative length of stay. MRC is still considered the noninvasive gold standard method for evaluating the bile ducts and their anatomical variations.
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Affiliation(s)
- Norman B Olmedo
- Department of Imaging and Radiology, College of Medical Sciences, Central University of Ecuador, Quito, ECU
| | - José Sebastião Dos Santos
- Department of Surgery and Anatomy, Hospital das Clinicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, BRA
| | - Jorge Elías Junior
- Department of Medical Imaging, Hematology, and Oncology, Ribeirão Medical School, University of São Paulo, Ribeirão Preto, BRA
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Shrestha P, Mansur DI, Karki S, Shrestha S, Maskey S, Chaudary R. Atypical Pattern of the Intrahepatic Biliary Duct on Magnetic Resonance Cholangiopancreatography in a Tertiary Care Centre: A Descriptive Cross-sectional Study. JNMA J Nepal Med Assoc 2022; 60:955-958. [PMID: 36705179 PMCID: PMC9795103 DOI: 10.31729/jnma.7658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction The liver possesses different patterns of intrahepatic duct confluences. Even though the typical pattern of the intrahepatic biliary duct is common, atypical variations are also frequently witnessed. The knowledge of the atypical intrahepatic biliary confluences is inevitable during hepato-biliary surgery to reduce post-operative complications. The aim of the study was to find out the prevalence of the atypical pattern of intrahepatic biliary duct pattern on magnetic resonanace cholangiopancreatography in a tertiary care centre. Methods This descriptive cross-sectional study was done in a tertiary care centre after receiveing ethical approval from the Institutional Review Committee [Reference number: KUSMS/IRC (248/2021)]. The branching patterns of the atypical intrahepatic biliary pattern were observed in Magnetic resonance cholangiopancreatography images and were classified. Convenience sampling was used. Point estimate and 95% Confidence Interval were calculated. Results Among 199 magnetic resonance cholangiopancreatography images, the atypical intrahepatic biliary duct was observed in 48 (24.12%) (18.18-30.06, 95% Confidence Interval) of the images. Conclusions The prevalence of the atypical intrahepatic biliary duct pattern is lower as compared to other studies done in similar settings. Keywords bile ducts; liver; magnetic resonance cholangiopancreatography.
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Affiliation(s)
- Pragya Shrestha
- Department of Anatomy, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal
| | - Dil Islam Mansur
- Department of Anatomy, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal
| | - Subindra Karki
- Department of Radiodiagnosis, Dhulikhel Hospital, Dhulikhel, Kavre, Nepal
| | - Sheprala Shrestha
- Department of Anatomy, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal,Correspondence: Dr Pragya Shrestha, Department of Anatomy, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal. , Phone: +977-9841658315
| | - Sunima Maskey
- Department of Anatomy, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal
| | - Roshan Chaudary
- Department of Radiodiagnosis, Dhulikhel Hospital, Dhulikhel, Kavre, Nepal
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Garcia S, Concepción AM, Wakoff C. Bile Leak Due to Luschka Duct Injury After Laparoscopic Cholecystectomy: A Case Report. Cureus 2022; 14:e28427. [PMID: 36176857 PMCID: PMC9512329 DOI: 10.7759/cureus.28427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 11/05/2022] Open
Abstract
Bile leak is a common complication after laparoscopic cholecystectomy. Anatomical variations in the biliary tree can go unnoticed by the surgical team and cause complications such as this. This case report presents a patient admitted to the emergency department a week after a laparoscopic cholecystectomy due to abdominal pain and nausea. After a computed tomography, the patient was brought to the operating room for an exploratory laparoscopy, where an injured Luschka duct was found. The biliary tree has many variations that the surgeon should be aware of to minimize the risk of complications of this nature after laparoscopic cholecystectomy. There are imagining techniques with various grades of effectiveness, but in the end, the surgeon’s expertise and experience are the main factors in avoiding these complications.
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Kajiwara M, Ishii F, Sasaki T, Nakashima R, Hasegawa S. Crucial Roles of the Assistant Surgeon During Laparoscopic Left Hemihepatectomy. Cureus 2022; 14:e24050. [PMID: 35573504 PMCID: PMC9095429 DOI: 10.7759/cureus.24050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2022] [Indexed: 11/05/2022] Open
Abstract
Background Although left hemihepatectomy has been widely performed via the laparoscopic approach, the roles of the assistant surgeon have not been well-documented so far. We herein present our standardized procedures of laparoscopic left hemihepatectomy without Spiegel’s lobe resection, focusing on the crucial roles of the assistant surgeon. Methods During laparoscopic left hemihepatectomy without Spiegel’s lobe resection, countertraction by the assistant surgeon is quite important especially during isolating the left Glissonean pedicle and transecting liver parenchyma. When securing the left hepatic pedicle using the Glissonean approach, the assistant surgeon pushes Segment 4 of the liver cranially and pulls the tape encircling the hepatoduodenal ligament caudally in the opposite way, orthogonal to the direction of the laparoscopic forceps toward the left portal triad. During liver parenchymal transection, the assistant surgeon pulls the hanging tape across the left lobe of the liver in order to provide a wide and stable liver transection plane. With this standardized technique, nine cases of laparoscopic left hemihepatectomy were performed over the last two years in our department, and the perioperative data were retrospectively analyzed. Results The median age of the nine patients was 70 years (range: 58 - 84 years). Most of the patients were males (77.8%). Five of nine patients were diagnosed with colorectal liver metastasis, two with hepatocellular carcinoma (HCC), one with inflammatory pseudotumor, and the other one with hepaticolithiasis. There were no conversions to open surgery. The median operative time and estimated blood loss were 337 minutes (range: 219 - 478 minutes) and 100 ml (range: 41 - 375 ml), respectively. The median length of postoperative hospital stay was nine days (range: 7 - 16 days). Major complications (Clavien-Dindo classification grade III or more) were not encountered in our cohort postoperatively. Conclusion We presented here our standardized assistant roles during laparoscopic left hemihepatectomy without Spiegel’s lobe resection, which was revealed to be safe and feasible in our cohort.
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Cawich SO, Sinanan A, Deshpande RR, Gardner MT, Pearce NW, Naraynsingh V. Anatomic variations of the intra-hepatic biliary tree in the Caribbean: A systematic review. World J Gastrointest Endosc 2021; 13:170-183. [PMID: 34163564 PMCID: PMC8209542 DOI: 10.4253/wjge.v13.i6.170] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/15/2021] [Accepted: 05/20/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In the classic descriptions of the human liver, the common hepatic duct forms at the confluence of left and right hepatic ducts. Many authors have documented variations in the intra-hepatic ductal system, but to the best of our knowledge there has been no report on bile duct variations in Caribbean populations.
AIM To evaluate the variations in bile duct anatomy using magnetic resonance cholangiography (MRC) in unselected patients at a major hepatobiliary referral centre in the Eastern Caribbean. Knowledge of the intra-hepatic biliary anatomy is important to optimize service delivery for any physician treating liver and biliary disorders.
METHODS This study was carried out at a tertiary referral hospital for hepatobiliary diseases in the Eastern Caribbean. We retrospectively evaluated magnetic resonance cholangiograms in 152 consecutive patients at this facility over a two-year period from April 1, 2017 to March 31, 2019. Two consultant radiologists experienced in MRC interpretation reviewed all scans and described biliary anatomy according to the Huang’s classification. A systematic review of published studies was performed and relevant data were extracted in order to calculate the global prevalence of each biliary variant. The variants in our population were compared to the global population.
RESULTS There were 152 MRCs evaluated in this study in 86 males and 66 females. There were 109 (71.7%) persons with “classic” biliary anatomy (type A1) and variants were present in 43 (28.3%) persons. There was no statistical relationship between the presence of anatomic variants and gender or ethnicity. We encountered the following variants: 29 (19.1%) type A2, 7 (4.6%) type A3, 6 (3.95%) type A4, 0 type A5 and a single variant (quadrification) that did not fit the classification system. Compared to the global prevalence, our population had a significantly greater occurrence of A1 anatomy (71.7% vs 62.6%; P = 0.0227) and A2 trifurcations (19.1% vs 11.5%; P = 0.0069), but a significantly lower incidence of A3 variants (4.61% vs 11.5%; P = 0.0047).
CONCLUSION There are significant differences in intra-hepatic biliary anatomy in this unselected Eastern Caribbean population compared to global statistics. Specifically, persons of Caribbean descent have a greater incidence of Huang A2 trifurcations and a lower incidence of Huang A3 variants.
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Affiliation(s)
- Shamir O Cawich
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine 000000, Trinidad and Tobago
| | - Alexander Sinanan
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine 000000, Trinidad and Tobago
| | - Rahul R Deshpande
- Department of Surgery, Manchester Royal Infirmary, Manchester M13 9WL, United Kingdom
| | - Michael T Gardner
- Department of Anatomy, University of the West Indies, Kingston KIN7, Jamaica
| | - Neil W Pearce
- Department of Surgery, Southampton University NHS Trust, Southampton SO16DP, Southampton, United Kingdom
| | - Vijay Naraynsingh
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine 000000, Trinidad and Tobago
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Janssen BV, van Laarhoven S, Elshaer M, Cai H, Praseedom R, Wang T, Liau SS. Comprehensive classification of anatomical variants of the main biliary ducts. Br J Surg 2021; 108:458-462. [PMID: 33723607 DOI: 10.1093/bjs/znaa147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/09/2020] [Accepted: 11/25/2020] [Indexed: 11/14/2022]
Abstract
This systematic review provides the most comprehensive overview of intrahepatic biliary anatomical variants to date. Additionally, it proposes a clinically focused, prevalence-based classification system based on meta-analysis of a large pooled dataset whilst incorporating the merits of previous classification systems.
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Affiliation(s)
- B V Janssen
- Hepato-Pancreato-Biliary Surgical Unit, University Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,Department of Surgery, Cancer Centre Amsterdam, Amsterdam University Medical Centre, Amsterdam, the Netherlands.,Department of Pathology, Cancer Centre Amsterdam, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - S van Laarhoven
- Hepato-Pancreato-Biliary Surgical Unit, University Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - M Elshaer
- Hepato-Pancreato-Biliary Surgical Unit, University Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - H Cai
- Department of Statistical Science, University College London, London, UK
| | - R Praseedom
- Hepato-Pancreato-Biliary Surgical Unit, University Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - T Wang
- Department of Statistical Science, University College London, London, UK
| | - S-S Liau
- Hepato-Pancreato-Biliary Surgical Unit, University Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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Naeem MQ, Ahmed MS, Hamid K, Shazlee MK, Qureshi F, Asad Ullah M. Prevalence of Different Hepatobiliary Tree Variants on Magnetic Resonance Cholangiopancreatography in Patients Visiting a Tertiary Care Teaching Hospital in Karachi. Cureus 2020; 12:e12329. [PMID: 33520527 PMCID: PMC7837639 DOI: 10.7759/cureus.12329] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Introduction Hepatobiliary tree variant anatomy is crucial to understand the preoperative planning of hepatobiliary surgeries. Although the presence of variant anatomy is not an absolute contraindication for liver transplantation, inadvertent mapping can lead to postoperative biliary complications. These variants are also important to be recognized in various hepatobiliary surgeries and interventional procedures. Magnetic resonance cholangiopancreatography (MRCP) is an excellent non-invasive imaging tool that can identify biliary anatomy. The purpose of the current study is focused on determining anatomical variants of the biliary tree on MRCP in our population visiting a teaching hospital in Karachi. Methods This cross-sectional study was conducted on patients referred to Dr. Ziauddin Hospital for MRCP. MRCP was performed on MAGNETOM Avanto, SIEMENS, Belgium, Germany. Images were analyzed on a workstation by two radiologists and a postgraduate trainee. A senior radiologist reviewed equivocal cases. SPSS 22.0 (SPSS Inc., Chicago, IL) was used for statistical analysis. Chi-square test was used to see the link between anatomical variants of biliary tree and gender. P-value of ≤0.05 was considered as statistically significant. Results We recruited 369 patients undergoing MRCP consecutively for our study. Out of 369, 342 patients were eligible for analysis (139 males and 203 females). Standard anatomy was found to be prevalent in 65.8%. Type 3 was the leading variant. A statistically significant difference was recorded for the type 2 anatomic variant which was more frequent in males than females (p-value <0.001), while types 1, 3, and 4 anatomic variants were found to be more in females than males but this difference was not statistically significant. Few other variants were also recorded. Conclusion This study is robust evidence regarding biliary variants in Pakistan. It is important to consider these variants in our region, owing to an increased trend of liver transplants and other hepatobiliary procedures.
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Swain B, Sahoo RK, Sen KK, G MK, Parihar SS, Dubey R. Evaluation of intrahepatic and extrahepatic biliary tree anatomy and its variation by magnetic resonance cholangiopancreatography in Odisha population: a retrospective study. Anat Cell Biol 2019; 53:8-14. [PMID: 32274243 PMCID: PMC7118263 DOI: 10.5115/acb.19.177] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 12/02/2019] [Accepted: 12/02/2019] [Indexed: 01/06/2023] Open
Abstract
Intrahepatic and extrahepatic anatomical knowledge is essential for pre procedural planning of liver transplantation, liver resection, complex biliary reconstruction and radiological biliary tree intervention. Indian data of biliary anatomy and its variation is scant in literature. The aim of our study is to find out the prevalence of common and uncommon pattern of biliary tree anatomy in magnetic resonance cholangiopancreatography (MRCP) in our population. A total of 1,038 cases of MRCP of population of Odisha were obtained from Picture Archiving and Communication System of the department and were reviewed by two senior radiologists for anatomical pattern and variations. The typical and most common pattern of right hepatic duct (RHD) branching was seen in 72.8% cases. The most common variant of RHD was trifurcation pattern of insertion of right anterior sectoral duct (RASD), right posterior sectoral duct and left hepatic duct (LHD) forming common hepatic duct (CHD) in 11.3% of cases. The common trunk of segment (SEG) II and III ducts joining the SEG IV duct was the most common LHD branching pattern in 90.3% of cases. The most common pattern of cystic duct was posterior insertion to middle third of CHD (42.8%). MRCP is the non-invasive imaging modality for demonstration of biliary duct morphology to prevent iatrogenic injury during hepatobiliary intervention and surgery.
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Affiliation(s)
- Bikramaditya Swain
- Department of Radiodiagnosis, Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, India
| | - Ranjan Kumar Sahoo
- Department of Radiodiagnosis, Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, India
| | - Kamal Kumar Sen
- Department of Radiodiagnosis, Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, India
| | - Manoj Kumar G
- Department of Radiodiagnosis, Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, India
| | - Shylendra Singh Parihar
- Department of Radiodiagnosis, Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, India
| | - Roopak Dubey
- Department of Radiodiagnosis, Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, India
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