Aberrant Left Main Bile Duct Draining Directly Into the Cystic Duct or Gallbladder: An Unreported Anatomical Variation and Cause of Bile Duct Injury During Laparoscopic Cholecystectomy
Hosein Shokouh-Amiri, MD, FACS, FICS; Mohammad Kazem Fallahzadeh, MD; Sophia T. Abdehou, MD; Miles Sugar, MD; Gazi B. Zibari, MD, FACS
Despite recent advances, iatrogenic bile duct injury remains one of the most common complications of lapa- roscopic cholecystectomy. Aberrant biliary tract anatomy is one of the major risk factors for iatrogenic bile duct injury. In this case report, for the first time, we report a case of aberrant left main bile duct draining directly into the cystic duct or gallbladder that presented with bile duct injury after laparoscopic cholecys- tectomy. We hope that the diagnostic and management approach used in this case will help physicians to identify and manage their patients should they face such a rare anatomy.
INTRODUCTION Despite improvements in laparoscopic technology and enhanced expertise in performing laparoscopic procedures, iatrogenic bile duct injury (IBDI) remains one of the most common complications of laparoscopic cholecystectomy (LC). 1-3 Aberrant biliary tract anatomy is one of the major risk factors for IBDI during LC. 2,3 We report a case of an aberrant anatomy of the biliary ductal system that resulted in a bile leak during LC at a local hospital. While the sur- geon observed the bile leak, he was not able to identify the source of the bile leak by conventional diagnostic workup and referred the patient to our center due to continued bile leak. By implementing a novel approach, we were able to identify that the bile leak was due to the unavoidable injury of an aberrant bile duct that, to our knowledge, has not been reported previously in the literature published in English. CASE REPORT A 71-year-old Caucasian woman underwent LC due to gallstone pancreatitis. The procedure was converted to open due to bile leak in the surgical field and the inability to find the source of the leak. A duct of Luschka was identi- fied and ligated. A drain was placed, and the abdomen was closed. Postoperatively, she continued to have a bile leak
through the Jackson-Pratt (J-P) drain. Therefore, she was taken back to the operating room the same day, but once again, no identifiable source of bile leak was found. Hence, a T-tube was inserted and intraoperative cholangiogram was obtained, which was initially interpreted as normal ductal anatomy with no evidence of leak (Figure 1-A). The abdomen was closed; however, the patient continued to have a bile leak postoperatively. With the suspicion of a bile duct anomaly, even though there was a T-tube in place, an endoscopic retrograde cholangiopancreatography (ERCP) was performed that was interpreted at the local hospital as normal without any radiologic evidence of extravasation (Figure1-B). Sphincterotomy was performed, and a biliary stent was placed to address any possible unidentified bile duct damage. The patient was observed for a fewweeks with a J-P drain in place to control biliary fistula. At this time, the patient was transferred to our hepatopancreatobiliary center seven weeks after the initial LC. With the high index of suspicion for the presence of an aberrant biliary anatomy and since all other relevant studies such as T-tube cholan- giogramand ERCP have already proven to be non-helpful, a cholangiogram through J-P drain was performed. This chol- angiogram finally resolved the diagnostic conundrum and illustrated a completely transected left main hepatic duct without any communication to the remaining part of the bili- ary system (Figure 1-C). A hepatobiliary iminodiacetic acid
J La State Med Soc VOL 166 September/October 2014 203
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