Difficult cannulation of the common bile duct due to a low junction with the cystic duct

A 33-year-old female with a mild elevation of liver transaminase was sent to the general surgery department for medical services due to upper-right abdominal pain for 2 weeks. A liquid dark area ~4 × 3 × 3 cm in size in the theoretical location of the pancreatic segment of the common bile duct was detected by abdominal CT with no enhancement of the cystic wall found in the enhanced CT scan. The patient was then diagnosed with a choledochal cyst based on the results of the radiological images preoperatively. During the operation, the isolated cystic dilatation was found in the middle part of the cystic duct, and its caudal portion was found behind the head of the pancreas and converged into the common bile duct at an acute angle and low insertion. According to the intraoperative evaluation, the female was then diagnosed with a cystic duct cyst (CDC). The surgery was converted to a laparotomy for the unclear structure and the possibility of anatomic variation of the bile duct. The caudal portion of the cystic duct was found communicated with the common bile duct with a narrow base, and the extrahepatic bile duct was not cystic. The CDC was removed in the surgery. One week later, the patient was discharged from the hospital for the disappearance of abdominal pain and normal liver transaminase and did not report any discomfort in the 1-month-long follow-up. The lessons drawn from this case were as follows: (1) the distinction between the relatively frequent choledochal cyst and the isolated CDC should always be taken in mind; (2) a surgical strategy should be given priority for an intraoperatively confirmed CDC; (3) a common bile duct exploration is recommended for patients with choledocholithiasis or jaundice.

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Agenesis of the gallbladder and cystic duct

Sao Paulo Medical Journal ◽

10.1590/s1516-31802002000600008 ◽

2002 ◽

Vol 120 (6) ◽

pp. 192-194 ◽

Cited By ~ 14

Author(s):

Jaques Waisberg ◽

Paulo Engler Pinto Júnior ◽

Paula Regina Gusson ◽

Paola Rossini Fasano ◽

Antônio Cláudio de Godoy

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Cystic Duct ◽

Intraoperative Cholangiography ◽

Diagnostic Aspects ◽

Rare Anomaly ◽

The Common

Agenesis of the gallbladder and cystic duct is a rare anomaly that is usually asymptomatic. The patient may present symptoms characteristic of cholelithiasis. Its surgical confirmation requires careful dissection of the common bile duct and intraoperative cholangiography or ultrasonography to be performed, to exclude the possibility of an ectopic gallbladder. The authors describe two cases of this unusual affection and comment on its clinical, pathophysiological and diagnostic aspects.

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Laparoscopic Management of Remnant Cystic Duct Calculi: A Retrospective Study

Annals of The Royal College of Surgeons of England ◽

10.1308/003588409x358980 ◽

2009 ◽

Vol 91 (1) ◽

pp. 25-29 ◽

Cited By ~ 39

Author(s):

Chinnusamy Palanivelu ◽

Muthukumaran Rangarajan ◽

Priyadarshan Anand Jategaonkar ◽

Madhupalayam Velusamy Madankumar ◽

Natesan Vijay Anand

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Cystic Duct ◽

Imaging Modality ◽

Operating Time ◽

Laparoscopic Management ◽

Subtotal Cholecystectomy ◽

Laparoscopic Excision ◽

The Common ◽

The Mean

INTRODUCTION Even though cholecystectomy relieves symptoms in the majority of cases, a significant percentage suffer from ‘postcholecystectomy syndrome’. Cystic duct/gall bladder remnant calculi is a causative factor. We present our experience with the laparoscopic management of cystic duct remnant calculi. PATIENTS AND METHODS We managed 15 patients with cystic duct remnant calculi from 1996 to 2007 in our institute. All these patients had earlier undergone laparoscopic subtotal cholecystectomy at our centre. They were successfully managed by laparoscopic excision of the remnant. RESULTS The mean duration between first and second surgery was 8.35 months (range, 6–10.7 months). The mean operating time was 103.5 min (range, 75–132 min). Duration of hospital stay was 4–12 days. There was a higher incidence of remnant duct calculi following laparoscopic subtotal cholecystectomy than conventional laparoscopic cholecystectomy 13/310 (4.19%) versus 2/9590 (0.02%). The morbidity was 13.33%, while there were no conversions and no mortality. CONCLUSIONS Leaving behind a cystic duct stump for too long predisposes stone formation, while dissecting too close to the common bile duct and right hepatic artery in acute inflammatory conditions is dangerous. We believe that the former is a wiser policy to follow, as cystic duct remnant calculi are easier to manage than common bile duct or vessel injury. Laparoscopic excision of the remnant is effective, especially when performed by experienced laparoscopists. ‘T’-tube is used to canulate the common bile duct in case the tissue is friable. Magnetic resonance cholangiopancreaticography is the imaging modality of choice, and is mandatory.

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