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.

INTRODUCTION

Anatomical anomalies of the biliary tree, such as an accessory hepatic duct or gallbladder duplication, are considered to be risk factors for bile duct injuries and open conversion during laparoscopic cholecystectomy (LC).[1] Therefore, precise pre-operative evaluation of the extrahepatic bile duct tract is important.[2] Drip infusion cholangiography with computed tomography (DIC-CT) is especially useful to evaluate the anatomy of the biliary tree.[3]

Single-incision LC (SILC) provides the advantages of better cosmetic result and less pain compared with conventional LC.[4] However, SILC has not become the standard approach because of a few disadvantages.[5] Here, we report a case of a woman with gallstone disease, who was preoperatively diagnosed with epigastric pain, with the right accessory hepatic duct merged with the cystic duct and who was successfully treated with SILC.

CASE REPORT

A 32-year-old woman with epigastric pain presented to the emergency department. A physical examination was unremarkable. Laboratory studies showed an elevated aspartate aminotransferase (AST, 68 U/L), alanine aminotransferase (ALT, 36 U/L), alkaline phosphatase (ALP, 167 U/L) and γ-glutamyl transpeptidase (205 U/L). Ultrasonography and magnetic resonance cholangiopancreatography (MRCP) revealed small gallstones in the gallbladder. CT did not identify gallstones. An elevated amylase (369 U/L) suggested common bile duct stones. Endoscopic sphincterotomy was performed to remove all the gallstones in the common bile duct. Involvement of an accessory hepatic duct was suspected during MRCP and endoscopic retrograde cholangiography (ERC) [Figure 1a and b].

Figure 1

(a) Magnetic resonance cholangiopancreatography (b) endoscopic retrograde cholangiography (c) anterior view of drip infusion cholangiography with computed tomography (d) posterior view of drip infusion cholangiography with computed tomography White and black arrowheads indicate the accessory right hepatic duct. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiography could not identify the position between the cystic duct and the right accessory hepatic duct. Three-dimensional images of drip infusion cholangiography with computed tomography shows that the cystic duct merged with the right accessory hepatic duct

Based on the patient's wish, SILC was planned for treating the gallstone disease. DIC-CT was additionally performed, and it demonstrated that the cystic duct branched from the right accessory hepatic duct, which dominated a posterior segment of the right hepatic lobe [Figure 1c and d].

During the operation, the patient was placed in supine position. A single-access system (EZ access and Lap-Protector, Hakko Co., Ltd.) enclosing working channels was introduced transumbilically under visual control. Three 5-mm ports were secured to the EZ access. A flexible 5-mm laparoscope, standard straight laparoscopic instruments and laparoscopic coagulation shears were used during the operation. The cystic duct was isolated while preserving the right accessory hepatic duct and the common bile duct [Figure 2a]. SILC was successfully performed. The operative time was 145 min, and the intraoperative blood loss was 1 mL. The patient was discharged 3 days' postoperatively, without complications [Figure 2b]. MRCP demonstrated that the right accessory hepatic duct was intact after 2 months.

Figure 2

(a) White arrowhead indicates the accessory right hepatic duct, and the white and black arrow show the cystic duct and common hepatic duct, respectively. (b) Post-operative scar after SILC. SILC: Single-incision laparoscopic cholecystectomy

DISCUSSION

In this report, we aimed to show the successful treatment with SILC of the right accessory hepatic duct that was merged with the cystic duct. DIC-CT was useful to preoperatively evaluate the relative positions of the cystic duct and the accessory right hepatic duct so that SILC was accomplished without complications and open conversion.

The cystic duct merging with the right accessory hepatic duct is a type of anomalous biliary tract, and its incidence rate is 0.9%. Although MRCP is the most widely used noninvasive means of evaluating biliary disease in Japan, DIC-CT depicts bile duct anomalies better than MRCP.[3] In this case, MRCP and ERC could not detect the accessory hepatic duct precisely. If anatomical anomalies of the biliary tree were suspected before LC, DIC-CT could be an effective tool to evaluate the anatomy of the biliary tree.

We did not perform fluorescent cholangiography during the operation because we were able to recognise the position of the cystic duct, the right accessory hepatic duct and the common hepatic duct. Fluorescent cholangiography could be helpful in case adequate surgical view could not be obtained during SILC.

SILC provides the advantage of good cosmetic result and less operative pain, but it has a few disadvantages as it is a difficult operation and time-consuming operation and has increased the risk of adverse events.[5] In our institution, SILC has been performed without complications so far, and it was useful in such a rare and complicated condition.

To the best of our knowledge, there have been no reports of cases wherein SILC was successfully performed in a patient with a preoperatively diagnosed accessory right hepatic duct.

In patients with an anomalous biliary tract, physicians could prevent biliary tract injury by using DIC-CT.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patients understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.