Introduction: Duplicated cystic ducts with a single gallbladder are extremely rare. We summarize and analyze the diagnose and treatment process of one case of gallstone disease in a patient with doublecystic duct who successfully treated with laparoscopic cholecystectomy. Presentation of case: A37-year-old female presented with signs and symptoms of acute cholecystitis . She was found to have an accessory cystic duct on laparoscopic cholecystectomy. Discussion: For patients with gallbladder stones and bile duct malformation, it is required that thesurgeon should have rich experience, carefully identify the anatomical structure of the biliary tract sys- tem. In the operation, cholangiography is feasible when the anatomic structure of biliary tract cannot be determined. Conclusion: Although laparoscopic surgeon is mature, when the anatomical structure cannot be identified, the conversion to laparotomy should be had in time to avoid the occurrence of secondary injuries.
2. Key wordsLaparoscopically; Cholecystectomy; Cholangiography
3. IntroductionDuplication of cystic duct is a rare variant, the variation increases risks of ductal injury, which requires surgeons to be familiar with bile duct variation, carefully identify the anatomy of the bile duct, and to prevent bile leakage [1]. Or else, there will need for open conversion and will produce postoperative complication. One case of laparoscopic cholecystectomy for a patient with double gallbladder duct is reported as follows. Patient information A 33-year-old married female, who presented to our hospital with intermittent right upper abdominal pain and discomfort for more than 5 years, aggravating for 3days.The pain started suddenly, sharp in character, radiating to right shoulder and epigastric area, associated with nausea and poor appetite. Past surgical and medical histories were negative. Clinical Findings The patient was in pain. Murphy’s sign was positive and right upper quadrant was tender without peritoneal signs. Vital signs, blood examination, electrocardiography and echocardiography were within normal range. Abdominal ultra sound showed multiple gallbladder stones with gallbladder atrophy, largest one about 10 millimeters in diameter. 3.4. Laparoscopic Surgeon After the preoperative examination was fully completed, contraindications were excluded and laparoscopic cholecystectomy was performed under general anesthesia. When the cystic duct and artery were dissected free from the cystic triangle laparoscopically, double cystic duct was found (Figure 1A), clipped, gall bladder removed. Finally, it was confirmed that the main gallbladder duct was from the common bile duct and the secondary gallbladder duct was from the right hepatic duct (Figure 1B) and there were multiple gall stones (Figure 2). Histopathological examination showed a feature of cholecystolithiasis with chronic cholecystitis. 4.5. Follow-Up and Outcomes Two weeks later, the patient was stable and no discomfort.
5. DiscussionThe incidence of double cystic duct variation was 0.025% [2]. At the 4th week of human embryo development, The caudal branches of the diverticulum elongate, the distal end dilates to form the gallbladder, and the proximal end narrows to form the gallbladder duct. If the diverticulum diverges into two caudal branches, which will cause the occurrence of double gallbladder or double cystic duct variation. In this case, if only one of the double cystic duct is ligated, bile leakage will inevitably result in the failure of the operation. If the ligation is cut close to the wall of the gallbladder, the remaining cystic duct will be longer, which may cause the socalled "small gallbladder" after the operation [3]. The study of bile duct anomalies began with Edward Boyden in 1926. Thirty years later, Caster and Flannery categorized cystic duct duplication into 3 types: (1)"Y "type, wherein 2 cystic ducts join to form a single cystic duct that then enters the common bile duct, (2) "H"type, in which each cystic duct independently joins the bile duct system at the common bile duct, right hepatic duct, left hepatic duct or common hepatic duct, and (3) trabecular type, in which one cystic duct enters the common bile duct while the other directly enters the liver parenchyma [4]. The double cystic duct in this case is of type "Y ". The surgical plan is determined according to the variation [5]. The treatment of extrahepatic biliary tract variation is usually surgery [6]. Laparoscopic surgery is feasible in the prevention and repair of biliary tract injury [7]. Double cystic duct malformation generally is found by accident without specific symptoms. The incidence of the disease is very low, preoperative diagnosis is difficult. In the actual clinical work, preoperative Magnetic Resonance Cholangio Pancreatography (MRCP) is no need [8]. However, MRCP can display various mutations [9], MRCP for bile duct variation has a high degree of sensitivity and specificity, the diagnosis of bile duct sensitivity was 66% [10], higher than that of CT and ultrasound examination. Significantly MRCP can evaluate bile duct shape, direction, size and site comprehensively without contrast agent [11]. Hence, MRCP become the gold standard for preoperative diagnosis of double cystic duct abnormalities. MRCP before LC can help prevent biliary damage and avoid misdiagnosing choledocholithiasis, so as to optimize the surgical plan and reduce the postoperative risks [12]. Of course, the final diagnosis depends on intraoperative confirmation. Cystic duct malformation will increase the incidence of iatrogenic biliary tract injury.Studies have found that LC combined with cholangiography can avoid the possible bile duct injury [4,13], because intraoperative cholangiography can develop the whole bile tree, which can not only show the filling defect caused by stones, but also find the anatomical abnormality of the biliary tract [14]. Intraoperative application of choledochoscopy can directly observe the lesions of intrahepatic and intrahepatic bile ducts, which can be treated by choledochoscopy, reducing the reoperation rate and postoperative residual stone rate [15]. LC combined with ERCP can help obtain the entire biliary system anatomy and avoid unnecessary loss [12]. ERCP can remove the stones in the common bile duct, but the effect of stones in the gallbladder is poor. Endoscopic Sphincterotomy (EST), which disrupts antireflux function and causes intestinal contents to flow back into the biliary system, is a potential factor of postoperative biliary tract infection. About 5% of patients may also be induced in Pancreatitis, suffering greater pain. Therefore, for patients undergoing surgery with endoscopic treatment, itsindicationsshould be strictlymastered [13]. (Table 1) showsliterature review of the reported cases of Double cystic duct.
6. ConclusionIn summary, careful dissection of the gallbladder triangle will become the key to prevent biliary tract injury. In the operation, cholangiography is feasible when the anatomic structure of biliary tract cannot be determined [1]. Although laparoscopic surgeon is mature, when the anatomical structure cannot be identified, the conversion to laparotomy should be had in time to avoid the occurrence of secondary injuries.
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Citation:Zhiyang Chen. Laparoscopic Cholecystectomy for a Patient with Double Gallbladder Duct: A Case Report. Annals of Clinical and Medical Case Reports 2020