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A novel classification of aberrant right hepatic ducts ensures a critical view of safety in laparoscopic cholecystectomy

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An Editorial to this article was published on 06 May 2020

Abstract

Background

Based on the spatial relationship of an aberrant right hepatic duct (ARHD) with the cystic duct and gallbladder neck, we propose a practical classification to evaluate the specific form predisposing to injury in laparoscopic cholecystectomy (LC).

Methods

We retrospectively investigated the preoperative images (mostly magnetic resonance cholangiopancreatography) and clinical outcomes of 721 consecutive patients who underwent LC at our institute from 2015 to 2018. We defined the high-risk ARHD as follows: Type A: communicating with the cystic duct and Type B: running along the gallbladder neck or adjacent to the infundibulum (the minimal distance from the ARHD < 5 mm), regardless of the confluence pattern in the biliary tree. Other ARHDs were considered to be of low risk.

Results

A high-risk ARHD was identified in 16 cases (2.2%): four (0.6%) with Type A anatomy and 12 (1.7%) with Type B. The remaining ARHD cases (n = 34, 4.7%) were categorized as low risk. There were no significant differences in the operative outcomes (operative time, blood loss, hospital stay) between the high- and low- risk groups. Subtotal cholecystectomy was applied in four cases (25%) in the high-risk group, a significantly higher percentage than the low-risk group (n = 1, 2.9%). In all patients with high-risk ARHD, LC was completed safely without bile duct injury or conversion to laparotomy.

Conclusions

Our simple classification of high-risk ARHD can highlight the variants located close to the dissecting site to achieve a critical view of safety and may contribute to avoiding inadvertent damage of an ARHD in LC.

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References

  1. Chung YH, Kim DJ, Kim IG, Kim HJ, Chon SE, Jeon JY, Jung JP, Jeong JC, Kim JS, Yun EJ (2012) Relationship between the risk of bile duct injury during laparoscopic cholecystectomy and the types of preoperative magnetic resonance cholangiopancreatiocography (MRCP). Korean J Hepatobiliary Pancreat Surg 16:17–23

    Article  Google Scholar 

  2. Noji T, Nakamura F, Nakamura T, Kato K, Suzuki O, Ambo Y, Kishida A, Maguchi H, Kondo S, Kashimura N (2011) ENBD tube placement prior to laparoscopic cholecystectomy may reduce the rate of complications in cases with predictably complicating biliary anomalies. J Gastroenterol 46:73–77

    Article  Google Scholar 

  3. Suhocki PV, Meyers WC (1999) Injury to aberrant bile ducts during cholecystectomy: a common cause of diagnostic error and treatment delay. AJR Am J Roentgenol 172:955–959

    Article  CAS  Google Scholar 

  4. Kurata M, Honda G, Okuda Y, Kobayashi S, Sakamoto K, Iwasaki S, Chiba K, Tabata T, Kuruma S, Kamisawa T (2015) Preoperative detection and handling of aberrant right posterior sectoral hepatic duct during laparoscopic cholecystectomy. J Hepatobiliary Pancreat Sci 22:558–562

    Article  Google Scholar 

  5. Ohkubo M, Nagino M, Kamiya J, Yuasa N, Oda K, Arai T, Nishio H, Nimura Y (2004) Surgical anatomy of the bile ducts at the hepatic hilum as applied to living donor liver transplantation. Ann Surg 239:82–86

    Article  Google Scholar 

  6. Onder H, Ozdemir MS, Tekbas G, Ekici F, Gumus H, Bilici A (2013) 3-T MRI of the biliary tract variations. Surg Radiol Anat 35:161–167

    Article  Google Scholar 

  7. Ausch C, Hochwarter G, Taher M, Holzer B, Rosen HR, Urban M, Sebesta C, Hruby W, Schiessel R (2005) Improving the safety of laparoscopic cholecystectomy: the routine use of preoperative magnetic resonance cholangiography. Surg Endosc 19:574–580

    Article  CAS  Google Scholar 

  8. Chaib E, Kanas AF, Galvao FH, D'Albuquerque LA (2014) Bile duct confluence: anatomic variations and its classification. Surg Radiol Anat 36:105–109

    Article  Google Scholar 

  9. Hirano Y, Tatsuzawa Y, Shimizu J, Kinoshita S, Kawaura Y, Takahashi S (2006) Efficacy of multi-slice computed tomography cholangiography before laparoscopic cholecystectomy. ANZ J Surg 76:693–695

    Article  Google Scholar 

  10. Hirao K, Miyazaki A, Fujimoto T, Isomoto I, Hayashi K (2000) Evaluation of aberrant bile ducts before laparoscopic cholecystectomy: helical CT cholangiography versus MR cholangiography. AJR Am J Roentgenol 175:713–720

    Article  CAS  Google Scholar 

  11. Ishii H, Noguchi A, Fukami T, Sugimoto R, Tada H, Takeshita H, Umehara S, Izumi H, Tani N, Yamaguchi M, Yamane T (2017) Preoperative evaluation of accessory hepatic ducts by drip infusion cholangiography with CT. BMC Surg 17:52

    Article  Google Scholar 

  12. Karakas HM, Celik T, Alicioglu B (2008) Bile duct anatomy of the Anatolian Caucasian population: Huang classification revisited. Surg Radiol Anat 30:539–545

    Article  Google Scholar 

  13. Ochiai T, Yamazaki S, Ohta K, Takahashi M, Iwai T, Irie T, Noguchi N, Takamatsu S, Kawamura T, Teramoto K, Arii S (2004) Is drip infusion cholecystocholangiography (DIC) an acceptable modality at cholecystectomy for cholecystolithiasis, considering the frequency of bile duct maljunction and intraoperative bile duct injury? J Hepatobiliary Pancreat Surg 11:135–139

    Article  Google Scholar 

  14. Uchiyama K, Tani M, Kawai M, Ueno M, Hama T, Yamaue H (2006) Preoperative evaluation of the extrahepatic bile duct structure for laparoscopic cholecystectomy. Surg Endosc 20:1119–1123

    Article  CAS  Google Scholar 

  15. Larobina M, Nottle PD (2005) Extrahepatic biliary anatomy at laparoscopic cholecystectomy: is aberrant anatomy important? ANZ J Surg 75:392–395

    Article  Google Scholar 

  16. Strasberg SM, Brunt LM (2010) Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg 211:132–138

    Article  Google Scholar 

  17. Strasberg SM, Brunt LM (2017) The critical view of safety: why it is not the only method of ductal identification within the standard of care in laparoscopic cholecystectomy. Ann Surg 265:464–465

    Article  Google Scholar 

  18. Tatsuaki S, Yasuo S, Takehiro O, Yasuhiro H, Yoshihiro N, Michihiko K, Kenta S, Yuji N, Taijiro S (2017) Multidetector CT in detection of troublesome posterior sectoral hepatic duct communicating with cystic duct. Br J Radiol 90:20170260

    Article  Google Scholar 

  19. Matsumura T, Komatsu S, Komaya K, Ando K, Arikawa T, Ishiguro S, Saito T, Osawa T, Kurahashi S, Uchino T, Yasui K, Kato S, Suzuki K, Kato Y, Sano T (2018) Closure of the cystic duct orifice in laparoscopic subtotal cholecystectomy for severe cholecystitis. Asian J Endosc Surg 11:206–211

    Article  Google Scholar 

  20. Honda G, Iwanaga T, Kurata M, Watanabe F, Satoh H, Iwasaki K (2009) The critical view of safety in laparoscopic cholecystectomy is optimized by exposing the inner layer of the subserosal layer. J Hepatobiliary Pancreat Surg 16:445–449

    Article  Google Scholar 

  21. Elshaer M, Gravante G, Thomas K, Sorge R, Al-Hamali S, Ebdewi H (2015) Subtotal cholecystectomy for "difficult gallbladders": systematic review and meta-analysis. JAMA Surg 150:159–168

    Article  Google Scholar 

  22. Shingu Y, Komatsu S, Norimizu S, Taguchi Y, Sakamoto E (2016) Laparoscopic subtotal cholecystectomy for severe cholecystitis. Surg Endosc 30:526–531

    Article  Google Scholar 

  23. Li JH, Zheng CZ, Ke CW, Yin K (2002) Management of aberrant bile duct during laparoscopic cholecystectomy. Hepatobiliary Pancreat Dis Int 1:438–441

    PubMed  Google Scholar 

  24. Mazer LM, Tapper EB, Sarmiento JM (2011) Non-operative management of right posterior sectoral duct injury following laparoscopic cholecystectomy. J Gastrointest Surg 15:1237–1242

    Article  Google Scholar 

  25. Flum DR, Dellinger EP, Cheadle A, Chan L, Koepsell T (2003) Intraoperative cholangiography and risk of common bile duct injury during cholecystectomy. JAMA 289:1639–1644

    Article  Google Scholar 

  26. Dili A, Bertrand C (2017) Laparoscopic ultrasonography as an alternative to intraoperative cholangiography during laparoscopic cholecystectomy. World J Gastroenterol 23:5438–5450

    Article  Google Scholar 

  27. Liu YY, Liao CH, Diana M, Wang SY, Kong SH, Yeh CN, Dallemagne B, Marescaux J, Yeh TS (2018) Near-infrared cholecystocholangiography with direct intragallbladder indocyanine green injection: preliminary clinical results. Surg Endosc 32:1506–1514

    Article  Google Scholar 

  28. Pesce A, Latteri S, Barchitta M, Portale TR, Di Stefano B, Agodi A, Russello D, Puleo S, La Greca G (2018) Near-infrared fluorescent cholangiography—real-time visualization of the biliary tree during elective laparoscopic cholecystectomy. HPB (Oxford) 20:538–545

    Article  Google Scholar 

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Acknowledgements

We are grateful to Kojiro Suzuki in the Department of Radiology, Aichi Medical University for valuable comments on radiological methods.

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Authors and Affiliations

  1. Department of Gastroenterological Surgery, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan

    Shintaro Kurahashi, Shunichiro Komatsu, Tatsuki Matsumura, Yasuyuki Fukami, Takashi Arikawa, Takuya Saito, Takaaki Osawa, Tairin Uchino, Shoko Kato, Kenta Suzuki, Yoko Toda, Kenitiro Kaneko & Tsuyoshi Sano

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  1. Shintaro Kurahashi
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  2. Shunichiro Komatsu
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  3. Tatsuki Matsumura
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  4. Yasuyuki Fukami
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  6. Takuya Saito
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  13. Tsuyoshi Sano
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Corresponding author

Correspondence to Shunichiro Komatsu.

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Disclosures

S Kurahashi, S Komatsu, T Matsumura, Y Fukami, T Arikawa, T Saito, T Osawa, T Uchino, S Kato, K Suzuki, Y Toda, K Kaneko and T Sano have no conflict of interest to declare.

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Kurahashi, S., Komatsu, S., Matsumura, T. et al. A novel classification of aberrant right hepatic ducts ensures a critical view of safety in laparoscopic cholecystectomy. Surg Endosc 34, 2904–2910 (2020). https://doi.org/10.1007/s00464-020-07610-8

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  • DOI: https://doi.org/10.1007/s00464-020-07610-8

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