Preoperative evaluation of the extrahepatic bile duct structure for laparoscopic cholecystectomy

A case of accessory hepatic duct entering cystic duct successfully treated by laparoscopic cholecystectomy for cholecystolithiasis

Although laparoscopic cholecystectomy is a well-established surgical procedure, an accessory hepatic duct (AcHD) entering the cystic duct is poorly understood. A 77-year-old woman with symptomatic cholecystlithiasis was referred to our hospital. Abdominal ultrasonography indicated several small stones in the gall bladder. Magnetic resonance cholangiopancreatography (MRCP) did not reveal an anomalous cystic duct. Dissecting the gall bladder bed at operation, AcHD entering the cystic duct was suspected. Intraoperative cholangiography revealed that B5 branch entered the cystic duct. We ligated the AcHD, and divided it. Laparoscopic cholecystectomy was completed, and the patient was discharged without any complication. A week after the operation, MRCP showed that ventral branch of B5 was dilated. The patient showed no symptom for more than a year. The present case exhibited extremely rare AcHD entering the cystic duct, which was hardly recognized before surgery. It is possible to recognize such anomalous variants with standard laparoscopic approach based on 2018 Tokyo Guidelines and with attention to the possibilities of AcHD entering the cystic duct.

Modified and dynamic intraoperativecholangiography during laparoscopic cholecystectomy in two patients with aberrant right posterior hepatic duct

Aberrant right posterior hepatic duct (ARPHD) is one of the anatomical anomalies of the bile duct. It is a risk factor for bile duct injury during laparoscopic cholecystectomy (LC). ARPHD can be diagnosed before surgery by magnetic resonance cholangiopancreatography or drip infusion cholangiographic-computed tomography. However, it is not easy to identify ARPHD during LC. Classic intraoperative cholangiography (IOC) procedure that does not lead to bile duct injury avoidance needs to be modified. In modified IOC, cannulation is performed from the infundibulum or neck of the gallbladder. We reported a modified and dynamic IOC procedure that can identify ARPHD safely and precisely during LC. The modified IOC provided direct evidence of no injury to ARPHD in 2 cases.

Anatomic variations of the extrahepatic biliary tree. A monocentric study and review of the literature

INTRODUCTION

The study of the anatomy of the extra hepatic bile ducts has demonstrated the existence of a significant number of variants which can be explained by hepato-biliary embryology. A good knowledge of this anatomy is essential for the interpretation of radiological examinations, and for a good practice of hepato-biliary and pancreatic surgery. Several imaging methods are used to study the anatomy of the bile ducts, including classical cholangiography, which is still practiced and very useful.

AIM

To study the modal anatomy (the most frequent) and the anatomical variants of the extrahepatic bile ducts through the interpretation of postoperative cholangiograms and to examine their implication on the surgical practice.

METHODS

This is a monocentric, retrospective observational study. It concerned any patient who underwent hepato-biliary or pancreatic surgery at the Department of General and Digestive Surgery of Farhat Hached University Hospital of Sousse between 2007 and 2016, and who received postoperative cholangiography. A data form was fulfilled for each patient.

RESULTS

Out of a total population of 293 patients, we identified 158 patients (53.9%) with anatomic variants of the extrahepatic bile ducts. The common bile duct was modally implanted in the second duodenum in 96.2% of cholangiographies and in the genu inferius in 3.8% of cases. The main pancreatic duct had a V-shaped implantation in 87.1% of cholangiograms, a U-shaped implantation in 4.2% of cases and a Y-shaped implantation in 7.1% of cases. The common bile duct had a modal aspect in 71.3% of cholangiograms, with 28.7% of anatomic variants, organized in 4 models. The cystic duct had a modal presentation in 80.9% of cases, and we recorded 6 other branching models (19.1% of cases). No significant difference was observed between the presence of anatomic variants on the one hand, and age, sex, conversion rate, intraoperative incidents, postoperative complications, postoperative hospital stay and overall hospital stay on the other hand.

CONCLUSION

Conventional cholangiography constitutes a more or less precise tool for detecting these anatomic variants and is therefore very useful in the practice of hepato-biliary surgery even after the advent of new techniques in this field. However, it also requires a more extensive and in-depth knowledge of these anatomic variants, which nevertheless remain quite frequent, and represent a source of surgical difficulties.

Evaluation of the usefulness of cystic duct three-dimensional computed tomography with non-contrast for before laparoscopic cholecystectomy and endoscopic transpapillary gallbladder drainage in comparison to magnetic resonance cholangiopancreatography

INTRODUCTION

The purpose of this study is to evaluate whether anatomical variations of the cystic duct and accessory bile duct can be grasped by cystic duct three-dimensional (3D)-computed tomography (CT) using non-contrast CT and to examine the possibility of omitting magnetic resonance cholangiopancreatography (MRCP).

METHODS

Of patients who underwent non-contrast abdominal CT between May and October 2019, those who underwent MRCP within 1 month before and afterwards were targeted. Seven assessors visually evaluated the cystic duct 3D-CT images on a 5-point scale. Average scores of ≥3 and <3 points were assigned as the good and poor groups, respectively. Regions of interest (ROIs) were placed inside the cystic duct and four places around it, and the CT values in those ROIs were measured. The CT value difference was calculated by subtracting the surrounding CT values from the CT value in the cystic duct and converting the result to an absolute value. The CT value difference was classified into good and poor groups, and statistical analysis was performed. Seven assessors evaluated anatomical variations of the cystic duct and the presence of the accessory bile duct. The results were compared with the MRCP interpretation results to calculate sensitivity, specificity, positive predictive value, and negative predictive value.

RESULTS

The average visual evaluation score was 3.8. The good and poor groups were comprised by 53 (85.5%) and 9 (14.5%) patients, respectively. The CT difference value averages were 54.7 and 15.9 for the good and poor groups, respectively, and the value was significantly higher in the good group (p = 0.001). The comparison results with MRCP were sensitivity=83.3%, specificity=78.0%, positive predictive value=47.6%, and negative predictive value=95.1%.

CONCLUSION

Cystic duct 3D-CT using non-contrast CT is a useful technique for understanding anatomical variations of the cystic duct and accessory bile duct. Our method may reduce the number of MRCP sessions performed.

A novel classification of aberrant right hepatic ducts ensures a critical view of safety in laparoscopic cholecystectomy

BACKGROUND

Based on the spatial relationship of an aberrant right hepatic duct (ARHD) with the cystic duct and gallbladder neck, we propose a practical classification to evaluate the specific form predisposing to injury in laparoscopic cholecystectomy (LC).

METHODS

We retrospectively investigated the preoperative images (mostly magnetic resonance cholangiopancreatography) and clinical outcomes of 721 consecutive patients who underwent LC at our institute from 2015 to 2018. We defined the high-risk ARHD as follows: Type A: communicating with the cystic duct and Type B: running along the gallbladder neck or adjacent to the infundibulum (the minimal distance from the ARHD < 5 mm), regardless of the confluence pattern in the biliary tree. Other ARHDs were considered to be of low risk.

RESULTS

A high-risk ARHD was identified in 16 cases (2.2%): four (0.6%) with Type A anatomy and 12 (1.7%) with Type B. The remaining ARHD cases (n = 34, 4.7%) were categorized as low risk. There were no significant differences in the operative outcomes (operative time, blood loss, hospital stay) between the high- and low- risk groups. Subtotal cholecystectomy was applied in four cases (25%) in the high-risk group, a significantly higher percentage than the low-risk group (n = 1, 2.9%). In all patients with high-risk ARHD, LC was completed safely without bile duct injury or conversion to laparotomy.

CONCLUSIONS

Our simple classification of high-risk ARHD can highlight the variants located close to the dissecting site to achieve a critical view of safety and may contribute to avoiding inadvertent damage of an ARHD in LC.

Randomized Trial of Near-infrared Incisionless Fluorescent Cholangiography

BACKGROUND

Incisionless near-infrared fluorescent cholangiography (NIFC) is emerging as a promising tool to enhance the visualization of extrahepatic biliary structures during laparoscopic cholecystectomies.

METHODS

We conducted a single-blind, randomized, 2-arm trial comparing the efficacy of NIFC (n = 321) versus white light (WL) alone (n = 318) during laparoscopic cholecystectomy. Using the KARL STORZ Image1 S imaging system with OPAL1 technology for NIR/ICG imaging, we evaluated the detection rate for 7 biliary structures-cystic duct (CD), right hepatic duct (RHD), common hepatic duct, common bile duct, cystic common bile duct junction, cystic gallbladder junction (CGJ), and accessory ducts -before and after surgical dissection. Secondary calculations included multivariable analysis for predictors of structure visualization and comparing intergroup biliary duct injury rates.

RESULTS

Predissection detection rates were significantly superior in the NIFC group for all 7 biliary structures, ranging from 9.1% versus 2.9% to 66.6% versus 36.6% for the RHD and CD, respectively, with odds ratios ranging from 2.3 (95% CI 1.6-3.2) for the CGJ to 3.6 (1.6-9.3) for the RHD. After dissection, similar intergroup differences were observed for all structures except CD and CGJ, for which no differences were observed. Significant odds ratios ranged from 2.4 (1.7-3.5) for the common hepatic duct to 3.3 (1.3-10.4) for accessory ducts. Increased body mass index was associated with reduced detection of most structures in both groups, especially before dissection. Only 2 patients, both in the WL group, sustained a biliary duct injury.

CONCLUSIONS

In a randomized controlled trial, NIFC was statistically superior to WL alone visualizing extrahepatic biliary structures during laparoscopic cholecystectomy.

REGISTRATION NUMBER

NCT02702843.

Single-incision laparoscopic cholecystectomy with the right accessory hepatic duct diagnosed preoperatively: A case report

Accessory hepatic duct or gallbladder duplication is considered to be a risk factor for bile duct injuries and open conversion during laparoscopic cholecystectomy (LC). A 32-year-old woman with epigastric pain was referred to our department. Gallstone disease in the gallbladder was diagnosed by ultrasonography and magnetic resonance cholangiopancreatography. The involvement of an accessory hepatic duct was suspected during endoscopic retrograde cholangiography. Drip infusion cholangiography with computed tomography showed that the cystic duct merged with the accessory right hepatic duct. Single-incision LC (SILC) was successfully performed without bile duct injury. The operative time and intraoperative blood loss were 145 min and 1 mL, respectively. The patient was discharged 3 days' postoperatively, without complications. The involvement of the accessory right hepatic duct is a rare anomaly and is considered to be a risk factor for bile duct injuries. However, obtaining pre-operative images enabled us to perform SILC successfully.

Preoperative evaluation of accessory hepatic ducts by drip infusion cholangiography with CT

BACKGROUND

This retrospective study aimed to investigate the incidence of each type of accessory hepatic duct by drip infusion cholangiography with CT (DIC-CT).

METHODS

Five hundred sixty nine patients who underwent preoperative DIC-CT and laparoscopic cholecystectomy were reviewed. Accessory hepatic ducts were classified as follows: type I (accessory hepatic ducts that merged with the common hepatic duct between the confluence of the right and left hepatic ducts and the cystic duct confluence), type II (those that merged with the common hepatic duct at the same site as the cystic duct), type III (those that merged with the common bile duct distal to the cystic duct confluence), type IV (the cystic duct merged with the accessory hepatic duct), and type V (accessory hepatic ducts that merged with the common hepatic or bile duct on the left side).

RESULTS

Accessory hepatic ducts were observed in 50 patients. Type I, II, III, IV, and V accessory hepatic ducts were detected in 32, 3, 1, 11, and 3 patients, respectively. Based on their drainage areas, the accessory hepatic ducts were also classified as follows: a posterior branch in 22 patients, an anterior branch in 9 patients, a combination of posterior and anterior branches in 16 patients, a left-sided branch in 2 patients, and a caudate branch in 1 patient. None of the patients with accessory hepatic ducts suffered bile duct injuries.

CONCLUSION

There are a number of variants of the accessory hepatic duct. DIC-CT is useful to detect the accessory hepatic duct.

Evaluation of the health-related quality of life for patients following laparoscopic cholecystectomy

PURPOSE

Laparoscopic cholecystectomy (LC) has become the standard procedure, and contributes to a shorter hospital stay. However, there have been no reports regarding when the patients can be discharged in terms of their health-related quality of life (HRQOL).

METHODS

The HRQOL was evaluated by using the SF-8 health survey (SF-8) 24-hour version in 127 consecutive patients treated from May 2007 to December 2008. The HRQOL and a visual analogue scale (VAS) score were assessed on the day before surgery and on postoperative day (POD) 1, POD2 and POD7.

RESULTS

All scores of the eight domains on POD1 were significantly decreased compared to the preoperative score (P < 0.05), and seven scores were still decreased on POD2, with the mental health (MH) domain showing an improvement. On POD7, the general health score improved to the preoperative level. The physical component summary 8 (PCS-8) was suppressed for all 7 days after LC. The mental health component summary 8 (MCS-8) was improved to the preoperative level on POD2, despite the significant suppression observed on POD1 (P < 0.05). The VAS score was higher in the low PCS-8 (PCS-8 < 42.4) and low MCS-8 (MCS-8 < 40.6) patients than in the high PCS-8 and high MCS-8 patients.

CONCLUSION

The HRQOL score demonstrated the improvement of the MCS-8 on POD2, which might suggest that a discharge of LC patients is appropriate on POD2 in terms of the patients' point of view.

Preoperative evaluation of the cystic duct for laparoscopic cholecystectomy: comparison of navigator-gated prospective acquisition correction- and conventional respiratory-triggered techniques at free-breathing 3D MR cholangiopancreatography

OBJECTIVE

To evaluate the quality of magnetic resonance cholangiopancreatography (MRCP) images obtained with a three-dimensional navigator-gated (NG) technique and compare findings with conventional respiratory-triggered (RT) images in pre-laparoscopic cholecystectomy patients.

METHODS

Turbo-spin-echo (TSE) RT-MRCP (average 242 s) and balanced turbo-field-echo (bTFE) NG-MRCP (average 263 s) were acquired at 1.5-T MRI for 49 pre-laparoscopic cholecystectomy patients. Two radiologists independently assessed image quality, visibility of anatomical structures, common bile duct (CBD) stones, and signal-to-noise ratios (SNRs). Interobserver agreement was also evaluated.

RESULTS

The anatomical details of the cystic duct were clearly demonstrated in 33 (67.3 %, reader A) and 35 (71.4 %, reader B) patients on RT-MRCP, and in 45 (91.8 %) and 44 (89.7 %) patients on NG-MRCP. On NG-MRCP, visualisation of the cystic duct (3.22/3.12), its origin (3.57/3.55), and the gallbladder(3.61/3.59) was statistically better than on RT-MRCP (2.90/2.78, 3.29/3.12, 2.98/2.88, respectively). The overall image quality was statistically better on NG-MRCP than RT-MRCP. Each technique identified the presence of CBD stones in all affected patients. The SNR was significantly higher on NG-MRCP (CHD 22.40, gallbladder 17.13) than RT-MRCP (CHD 17.05, gallbladder 9.30). Interobserver agreement was fair to perfect.

CONCLUSION

Navigator-gated MRCP is more useful than respiratory-triggered MRCP for evaluating the gallbladder and cystic duct in patients scheduled for laparoscopic cholecystectomy.

KEY POINTS

• Magnetic resonance cholangiopancreatography (MRCP) provides important cystic duct information before laparoscopic cholecystectomy. • Navigator-gated (NG) MRCP images were better than conventional respiratory-triggered (RT) MRCP. • The signal-to-noise ratio was significantly higher for NG-MRCP than for conventional RT-MRCP. • Balanced turbo-field-echo NG-MRCP is useful for evaluating the gallbladder and cystic duct.

Relationship between the risk of bile duct injury during laparoscopic cholecystectomy and the types of preoperative magnetic resonance cholangiopancreatiocography (MRCP)

Backgrounds/Aims

Bile duct injury is one of the potential severe complications that can occur during laparoscopic cholecystectomy, which can be cause by anatomic variations in the confluence of the bile duct. Recently magnetic resonance cholangiopancreatiocography (MRCP) has become a helpful tool to detect bile duct variation on a preoperative basis and to prevent bile duct injury during laparoscopic cholecystectomy, as well other hepatic surgeries. This study aimed to clarify the types of bile duct on MRCP and to search for a method of avoiding injury during laparoscopic cholecystectomy.

Methods

Between January 2009 and December 2010, 277 patients underwent laparoscopic cholecystectomy with preoperative MRCP in our institution. On a retrospective basis, the bile ducts were categorized into 5 types according to the Couinaud classification system.

Results

The proportion of types was revealed type A (70.4%), type B (8.7%), type C (19.5%), type D (0.7%), type E (0%), and type F (0.7%), respectively. Bile duct injury occurred in 4 cases (1.4%) during laparoscopic cholecystectomy. In particular, the possibility of aberrant extrahepatic confluence (Type C and F) represented the highest risk of duct injury (OR=11.89 [CI: 1.21-116.53]).

Conclusions

Preoperative evaluation of the bile duct anatomy is important to avoid injury of duct during laparoscopic cholecystectomy. Specific types of bile duct variation should be considered as a high risk group for bile duct injury.

ENBD tube placement prior to laparoscopic cholecystectomy may reduce the rate of complications in cases with predictably complicating biliary anomalies

BACKGROUND

The risk factors predisposing to bile duct injury or postoperative bile leakage associated with laparoscopic cholecystectomy (LC) include the presence of an accessory hepatic duct, the anomalous cystic duct confluence, and duct of Luschka. One method to prevent bile duct injury is preoperative placement of an endoscopic nasobiliary drainage tube (ENBD assisted LC). The aims of this investigation are first, to report the incidence of bile duct anomalies according to the classification system proposed by Wakayama Medical University and second, to evaluate the efficacy of ENBD assisted LC with regard to prevention of intraoperative bile duct injury and postoperative bile duct injury or leakage.

METHODS

A total of 1,835 consecutive LCs performed at our institution during a recent 10-year period were reviewed.

RESULTS

Anomalous cystic duct confluence was detected in 11 cases and an accessory hepatic duct was detected in 37 cases. These anomalies were risk factors for bile duct injury in our series. However, there was no significant difference in the length of surgery, conversion rate to laparotomy, or frequency of bile duct injury or leakage between the standard LC group and ENBD assisted LC group.

CONCLUSION

A bile duct anomaly was seen in 2.6% of LC cases. Placement of an ENBD tube prior to LC in predictably complicating bile duct anomalies may have successfully decreased the incidence of complications.

The "inside approach of the gallbladder" is an alternative to the classic Calot's triangle dissection for a safe operation in severe cholecystitis

BACKGROUND

External dissection of Calot's triangle and the gallbladder associated with complete cholecystectomy is considered the gold standard technique to achieve a safe cholecystectomy. However, in severe acute or chronic cholecystitis, the laparoscopic application of this standard technique may be technically difficult, with an increased risk of bile duct injury, even in the hands of an experienced surgeon.

METHODS

In a consecutive series of 552 cholecystectomies, 39 patients (7.1%) with difficult local conditions within Calot's triangle, such as gangrenous cholecystitis (three patients), severe scleroatrophic cholecystitis with or without anomalous right hepatic duct (24 and 10 patients, respectively), or Mirizzi syndrome (seven patients), underwent a routine exclusive "endovesicular approach" as an alternative to dissection of Calot's triangle prior to further subtotal cholecystectomy. All patients were examined by control cholangiography 3 months postoperatively to confirm the safety of the technique.

RESULTS

The operation was well tolerated by all patients with only 15.4% minor complications. Intraoperative cholangiography was feasible in 79.5%. There were no postoperative biliary or infectious complications. At 4.3 months follow-up, all patients were symptom-free, except for two patients (5.1%) with residual common bile duct stones which were successfully treated by endoscopic sphincterotomy.

CONCLUSIONS

An endovesicular approach for gallbladder dissection followed by subtotal cholecystectomy is a safe alternative to the classic Calot's dissection in the case of severe cholecystitis or difficult local conditions. This technique is recommended as an attractive solution to prevent bile duct injury, particularly when severe inflammation is associated to extrahepatic anatomic variants of the biliary tree.

Biliary anatomy on 3D MRCP: Comparison of volume-rendering and maximum-intensity-projection algorithms

PURPOSE

To compare volume-rendering (VR) and maximum-intensity-projection (MIP) of three-dimensional T2-weighted turbo spin-echo magnetic resonance cholangiopancreatography using a free-breathing navigator-triggered prospective acquisition correction (3D-TSE-PACE-MRCP) to define biliary anatomies.

MATERIALS AND METHODS

VR and MIP images of 3D-TSE-PACE-MRCP for 102 patients were retrospectively evaluated. Interpretation of cystic duct variation and biliary branching patterns of each image were recorded independently by two radiologists in a blinded fashion. Interpretation confidence on a five-point scale was compared using the Wilcoxon signed-rank test. The McNemar test was used to compare the accuracies of each reformation with the reference standard obtained by consensus interpretation of both the images and source images.

RESULTS

The reference standard identified all biliary bifurcations and 95 of 102 cystic duct confluences (93.1%). VR findings agreed with the reference standard findings more often than MIP with regard to cystic duct variation (94 [92.2%] vs. 76 [74.5%], P<0.01) while there was no significant difference for biliary branching patterns (99 [97.1%] vs. 92 [90.2%], P=0.092). The mean confidence score was significantly higher with VR than MIP with regard to both cystic duct variation and biliary branching patterns (3.7 vs. 2.4; P<0.01; 4.1 vs. 3.3; P<0.01).

CONCLUSION

VR reformation of 3D-TSE-PACE-MRCP defines biliary anatomies more accurately than MIP.