Choledochal cyst with an aberrant right cholecysto-hepatic duct draining into cystic duct and a review of literature.

Sir,

A thorough knowledge of variations in the anatomy of gallbladder, bile ducts, the arteries that supply them and the liver are important to a surgeon. Failure to recognize these variations may lead to inadvertent ductal ligation, biliary leaks and strictures after biliary tract surgery.[1] Aberrant bile duct is thought to be the result of normal variation in the development of the biliary system, and its incidence is as low as 5% in the normal population.[2]

A 9-year-old female child presented with complaints of right upper quadrant pain associated with intermittent low grade fever, nonbilious vomiting and jaundice was diagnosed with a type four choledochal cyst with an accessory duct opening into the cystic duct. The child underwent a choledochal cyst excision with choledocho-jejunostomy with a roux-en-y jejuno-jejunostomy. The accessory duct was visualized after laying open the cystic duct and was incorporated in the choledocho-enterostomy. The child had an uneventful postoperative recovery.

An aberrant bile duct is the only bile duct draining a particular hepatic segment and drains directly into the extra-hepatic biliary tree, whereas an accessory one is an additional bile duct draining the same area of the liver.[3]

It is more commonly seen on the right side with the incidence of 4.6-8.4%. It frequently drains into common hepatic duct, common bile duct or even left hepatic duct. The anomalous drainage of an aberrant right hepatic duct into cystic duct is relatively rare.

Recently, a few authors have noticed a high degree of association between biliary anomalies and choledochal cysts.[4] Oversight of the existence of an aberrant bile duct during the operation might lead to severe biliary leakage, biliary peritonitis, biliary fistula or abscess formation. Arbitrary ligation of an aberrant bile duct that independently drained a liver segment will obstruct the corresponding intrahepatic bile duct and result in segmental cirrhosis.[1234] The knowledge of aberrant anatomy of biliary tract would be important for a surgeon to avoid any inadvertent complications during any biliary surgery. With surgical advancement into laparoscopic and minimally invasive techniques, the basic principle of sound anatomic knowledge and relationships between the biliary tracts, hepatic and portal vessels is not outdated. Bile duct injury is one of the most serious complications during laparoscopic hepato-biliary surgeries and this rate is amplified when there are associated variations in the anatomy of the biliary tract.