[Laparoscopic cholecystectomy--accessory bile ducts].
BACKGROUND
Modern medical technology (ultrasonography, intraoperative radiologic contrast methods, ERC, CT and NMR) help in performing laparoscopic cholecystectomy and operative procedures on bile ducts. The safe performance of these operative procedures requires good knowledge of clinical anatomy. In spite of excellent laparoscopic visualization, perioperative lesions of vascular structures or extrahepatic (especially accessory) bile ducts during laparoscopic cholecystectomy are a frequent cause of intra- and postoperative complications. Therefore, we wish to point to the potential risk of running into accessory bile ducts on dissection within or around the cystohepatic triangle, which may entail some overlooked and untreated lesions.


METHODS
Accessory bile ducts originate from the liver parenchyma and may enter a large bile duct or gallbladder at any location, or can directly enter the intestine. The accessory bile ducts encountered on cholecystectomy or bile duct procedure call for special attention. We found accessory bile ducts in 13 (0.52%) patients during the procedure of laparoscopic cholecystectomy. There are three groups of 'risky' accessory bile ducts that can be encountered during laparoscopic cholecystectomy. Group I includes accessory bile ducts encountered on gallbladder removal from its support: 1) Luschka's subvesical accessory bile duct was found in six (46.1%) patients. A lesion to these ducts was intraoperatively observed in three (23.1%) patients, whereas in another three (23.1%) patients it was only detected and treated on reoperation; 2) the hepatocystic bile duct enters gallbladder directly from liver parenchyma, in the area of the gallbladder lobe. A hepatocystic accessory bile duct was identified during one (7.7%) laparoscopic cholecystectomy, when the duct lumen was observed on the gallbladder removal from the lobe, and another one (7.7%) was only identified on reoperation. Group II comprises accessory bile ducts encountered during dissection in the cystohepatic triangle, between the two hepatovesical plicae: 1) the hepatocystic accessory bile duct runs from liver parenchyma into the cystic duct within the cystohepatic triangle. Bile leak from a bile duct approaching the cystic duct immediately below the clip was observed on reoperation in one (7.7%) patient; 2) the hepatohepatic accessory bile duct drains a part of the liver and runs into the common hepatic duct within the cystohepatic triangle. During one (7.7%) dissection, another delicate bile duct originating from liver parenchyma was detected upon cystic duct clipping. Bile leak from a bile duct running into the common bile duct before entering the properly occluded cystic duct was observed on one (7.7%) reoperation; 3) anastomotic accessory bile ducts connect cystic duct with the common hepatic duct, or connect gallbladder, which has its own cystic duct, with the common hepatic duct or right hepatic duct. In our laparoscopic practice, we did not encounter this type of accessory bile ducts. Group III includes accessory bile ducts observed in the laparoscopic operative field, beyond the cystohepatic triangle, during cholecystectomy and bile duct procedures: 1) the hepatocystic accessory bile duct leaves liver parenchyma and enters the gallbladder at various sites. Stumps of two such accessory bile ducts (15.4%) were detected on reoperation. One entered the gallbladder below the cystic duct entry, and the other approached the gallbladder from above.


RESULTS
Reoperation following laparoscopic cholecystectomy was required in 15 (0.6%) patients. In eight (53.3%) of these, the reason for reoperation was untreated lesion of accessory bile duct in eight (53.3%), other untreated minor lesions of the cystic duct in five (33.3%), and lesions of the hepatocystic duct in two (13.3%) patients. Out of the eight patients reoperated on for untreated lesion of accessory bile duct, reoperation was indicated by external biliary secretion by drain for more than 7 days in three (37.5%), and by the development of biliary peritonitis with the symptom of pain in five (62.5%) patients. Right-sided shoulder pain and elevated body temperature were recorded in two (40.0%) patients each, whereas abdominal distension with pronounced local defense and hyperbilirubinemia were observed in four (80.0%) patients each. A combination of these symptoms was present in the majority of patients. The prevalence of symptoms was consistent with literature reports. Of the eight patients reoperated on for lesions of accessory bile ducts, the lesion was managed by repeat laparoscopy procedure in five (62.5%) and by laparotomy in three (37.5%) patients. There was no mortality.


CONCLUSIONS
Besides technical skill and experience, good knowledge of the clinical anatomy of accessory bile ducts is required to reduce the incidence of postoperative biliary secretion. Based on our own experience, lesions to accessory bile ducts are the most common cause of postoperative complications.
Balija
Milivoj
M
Kirurski odjel, Opća bolnica Zabok, Zabok, Hrvatska. milivojb@yahoo.com
Huis
Marijan
M
Szerda
Ferenc
F
Bubnjar
Josip
J
Stulhofer
Mladen
M
D001652:Bile Ducts / Q000002:abnormalities* / Q000293:injuries / Q000601:surgery; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000379:methods; D006801:Humans; D007431:Intraoperative Complications; D012086:Reoperation