Aberrant biliary ducts (Luschka's ducts) in a laparoscopic cholecystectomy

Aberrant biliary ducts represent a morphological anomaly rather than an anatomical variation of the biliary tree. These ducts are described in 20 to 50% of the patients, and their existence can sometimes explain the origin of certain cases of biliary peritonitis. We present a video of a standard laparoscopic cholecystectomy for symptomatic cholelithiasis and the management of biliary leaks due to the section of the Luschka’s ducts. This video is recommended for digestive surgeons.

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Aberrant biliary ducts (Luschka's ducts) in a laparoscopic cholecystectomy

Authors

B Dallemagne, J Marescaux

Abstract

Aberrant biliary ducts represent a morphological anomaly rather than an anatomical variation of the biliary tree. These ducts are described in 20 to 50% of the patients, and their existence can sometimes explain the origin of certain cases of biliary peritonitis.
We present a video of a standard laparoscopic cholecystectomy for symptomatic cholelithiasis and the management of biliary leaks due to the section of the Luschka’s ducts. This video is recommended for digestive surgeons.

Classification

clinical cases

Keywords

Aberrant biliary ducts, Luschka\'s ducts, laparoscopic cholecystectomy

Media type

Surgical video

Duration

05'03''

Publication

2008-11

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E-publication

WeBSurg.com, Nov 2008;8(11).
URL: http://www.websurg.com/doi-vd01en2435.htm

Aberrant biliary ducts (Luschka's ducts) in a laparoscopic cholecystectomy

1. Aberrant biliary duct introduction 00'15''

The aberrant biliary ducts also called vasa aberrantia represent a morphological anomaly rather than an anatomical variation of the biliary tree. These ducts should be known by the surgeon because their existence can sometimes explain the origin of certain cases of biliary peritonitis or on occasion a chole-peritonitis following division, for example of the left hepatic triangular ligament. In fact, the aberrant biliary ducts are described in between 20 to 50 per cent of the patients. These aberrant biliary ducts usually never communicate with the gallbladder. In comparison, a hepatocyst duct communicates with the gallbladder. In this video, we just show a case of cholecystectomy where we found some biliary leakage coming from the liver bed. It’s difficult to know exactly if it is an aberrant duct, which means that it does not communicate with the gallbladder or if it is a hepatocyst duct. The difference usually between those 2 is that the 2nd one drains one part of the liver as compared to the aberrant ducts, which do not drain any compartment of the liver.

2. Gallbladder dissection and bile leakage 01'42''

In this video we can see that after clipping the cystic duct and starting the dissection of the gallbladder from the liver bed, we encounter some bile leakage. Initially, the surgeon may think that the gallbladder has been perforated, but while reviewing the video and at the end of the operation, in fact this bile leakage corresponds to some injury of biliary duct running into the fossa of the gallbladder.

3. Aberrant ducts identification 02'16''

Apparently in the video, we have the feeling that it is a duct that communicates with the gallbladder, which is not the true definition of the Luschka’s duct. Nevertheless, it’s important to identify these small ducts and try to do the biliostasis when performing the cholecystectomy. Just remember that in open surgery, the basic rule was to drain all the cholecystectomy in order to avoid this postoperative bile leakage. After dissection of the gallbladder from the liver bed, it’s very important to carefully inspect this bed and usually with the new technology and the high definition camera, we can identify these very small structures. Usually, clips or sutures are necessary to control these small ducts.

4. Cystic duct stump reinforcement 03'17''

In this patient, the cystic duct was quite large so we reinforced the cystic stump with the use of an Endoloop, which is safer than 2 clips and after lavage of the operative field, we still found some bile leakage. So we did a careful inspection of the liver bed and found another biliary duct, which was also controlled with application of laparoscopic clips. In some patients, this clip application is not feasible and then it’s necessary to use very small sized sutures to control the bleeding. After having found 2 small ducts, we continue the inspection and we had the feeling of finding a 3rd one, which probably was only a small fibrous tract but for safety reasons, we also applied a clip on this structure. So probably in this patient, there were communicating ducts between the liver bed and the gallbladder but the possibility is also to have a long subvesicular duct running in the liver bed with small perforations at different levels.

5. Gallbladder extraction 04'45''

At the end of the operation, the gallbladder was extracted into an Endo-bag, and of course in this very patient, we left drainage under the liver. This drain was removed 24 hours after the surgery and the patient outcome was uneventful.