Study of Cystic Duct Anatomy and Its Variations Using a Laparoscope

STUDY OF CYSTIC DUCT ANATOMY AND ITS VARIATIONS USING A LAPAROSCOPE

MIAN AZHAR AHMAD*, MUHAMMAD TAHIR*, MIAN MAZHAR AHMAD*, NAWAB MOHAMMAD KHAN*, ASMATULLAH* 1Assistant Professor of Anatomy, Postgraduate Medical Instituite/Ameer-ud-Din Medical College, 2Professor of Anatomy (PhD Anatomy), University of Health Sciences, Lahore, 3Chief Laproscopic Surgeon, FCPS, DHQ hospital Sahiwal. 4HEC Approved Professor of Anatomy (PhD Anatomy), King Edward Medical University, Lahore. 5Associate Prosfessor, University of the Punjab, Lahore. Correspondence: Mian Azhar Ahmad* Assistant Professor of Anatomy, Postgraduate Medical Instituite/Ameer-ud- Din Medical College,Lahore-Pakistan.

ABSTRACT Objectives: To know in detail the anatomy of cystic duct and to assess frequency of the anatomical variations of cystic duct using a laparoscope Study design: It was a descriptive cross-sectional study. Place and duration of study: This study was conducted in five state of the art teaching hospital of Punjab, from 15th May 2012-2014. Methadology: Non-probabilty convenient sampling technique was employed. All the patients fulfilling the inclusion criteria were selected for study of anatomy of cystic duct and its variations. The exploration of Hepatobiliary Triangle, observing evaluating and taking photographic evidence of its boundaries and its contents on endoscopic visualization was recorded by DVD recorder. Medical grade video monitor was used to display and document anatomical variations. Each observant of anatomical variations was documented by photographs. Results: variations of cystic duct in current research work were found to be 20,12%. In 79.88% patients normal anatomy of cystic duct was demonstrated. Conclusion: Laparoscopic surgeons must knownormal anatomy of cystic duct and its variations, toavoid biliary injuries and other major postoperative complications5. These injuries can result into significant morbidity and even mortality.

Keywords: Cystic duct, Anatomical variations, Laparoscopic Cholecystectomy.

INTRODUCTION duct cancer and pancreatitis have link with the length In early days Laparoscope was used mainly used for and the position of common bile duct and cystic duct7. diagnosis and therapeutic purposes in obstetrics and Insertion of the cystic duct into the left hepatic duct,or gynecology1. Induction of videolaparoscopy motivated right hepatic duct and insertion of the left posterior general surgeons to use this technology as their hepatic duct directly into the cystic duct are considered treatment modality2.Right and left hepatic ducts join to rare 8. While exploring Calot triangle during form common hepatic duct. Cystic duct unites with laparoscopic cholectecystomy,cystic duct or bile duct common hepatic duct from its lateral position to make injury is the most serious complication 9. common bile duct. This composition of normal Laparoscope Cholecystectomy consists of the extrahepatic biliary tract is present in around 60% of the ligature of the cystic artery and the cystic duct for the patients3,4. Variations frequently occure and may be subsequent removal of the gallbladder. That is encountered during Laparoscopic cholecystectomy. particularly relevant when appreciating the severity of Cystic duct variations can create problems for complications such as hemorrhage, leakage of bile into Laparoscopic surgeons.In order to avoid significant the peritoneal cavity, and portal vein thrombosis, ductal injury, laparoscopic surgeons must understand associated with poor execution of the procedure. variable anatomy of the cystic duct and cysticohepatic Careful exploration of Calot’s triangle and exact junction5,6. Bile duct stones, Mirizzi’s syndrome, bile identification of extrahepatic biliary tree is important to

PAKISTAN POSTGRADUATE MEDICAL JOURNAL Vol. 23 No. 4 Oct. – Dec. 2012 114 MIAN AZHAR AHMAD*, MUHAMMAD TAHIR*, MIAN MAZHAR AHMAD et al avoid biliary complications during laparoscopic variations e in total of 500 non-emergency adult cholecystectomy. Improper identification may lead to Pakistani individuals of both sexes, including 350 injury, division or ligation of major bile ducts or women and 150 men,age 16 to 78 years,who underwent arteries.anatomy and pathology of biliary tract exploration of cystic duct during laparoscopic preoperatively10. cholecystectomy for different gallbladder diseases from May 2012 to January 2014, amongst them 388 patients MATERIAL AND METHODS with cholecystitis due to gallstones, and 112 with Study Design and Plan: After nessasary approval by gallbladder polyps, were studied. Advance Studies and Research Board (AS&RB),the institutional review board,of University of the RESULTS Punjab,this descriptive prospective cross sectional Normal cystic ductwas found in 79.88%. Absent cystic (hospital based)study was carried out in five teaching duct was noted in 0.12%, Short cystic ductin hospitals of Pakistan e,g. Lahore General Hospital, 8.96%,Long cystic ductin 4.04%,Double cystic duct in Shaikh Zayed Hospital Lahore,DHQ Hospital Sahiwal, 1.85%, Spiral cystic ductin 3.15%, Accessory cystic Mayo hospital, Jinnah hospital with best facilities for duct in 1.78%and Adherent cystic duct within the this research work and highly skillful Laparoscopic Calot's triangle was demonstrated in 0.12%. team available.The patients were selected by non In 6 cases we found long cystic duct in which the probability purposive technique.Sample size was cystic duct courses parallel to common hepatic duct and calculated through Open-Epi website with level of is lowly inserted into common hepatic duct.Short cystic significance 6%, margin of error 5% and frequency of duct found in 8.96%,was the most common variation 22.5 %. observed in the study. In one case cystic duct originated from right hepatic duct. In 2 cases cystic duct originated Data collection procedure: Convenient sampling from left hepatic duct. In 01 cases cystic duct originated technique was used for selection of patients. All patients from their bifurcations. In one cases cystic duct attending surgical out patients departments were originated from accessory cystic duct. In three cases we examined with ultrasound before surgery. Surgical team noted left sided insertion of cystic duct with anterior comprised two consultant Laparoscopic surgeons, two course. In 4 cases we noted left sided insertion of cystic surgical residents, two minimally invasive surgery duct with posterior course. In 5 cases we noted left fellows, and one attending surgeon/authorized sided insertion of cystic duct with spiralcourse.In01 Anatomist (myself).We evaluated cystic duct and its cases we documented cystic duct connected with variable morphological patterns during laparoscopic parahepatic duct and itself opening into common cholecystectomy at different Pakistani centers during 2 hepatic duct. Absent cystic duct was displayed in 0.12% years period. Laparoscopic equipments were produced cases and short cystic duct was observed in 8.96% by Stryker and duodenoscopes with a channel diameter cases. Doubling of cystic duct was found in 1.8% cases of 3.5 cm and 4.2 cm respectively were from Olympus. while right hepatic duct draining into the cystic duct All the patients fulfilling the inclusion and was shown in 3% cases. exclusion criteria were selected for this study. Observation, evaluation and photographic evidence of DISCUSSION cystic duct and its variations on endoscopic Unrecognized variant anatomy of cystic duct can be a visualization was recorded by DVD recorder. Medical source of confusion and intraoperative injury to cystic grade video monitor was used to display and document duct, resulting into postoperative biliary leakage. anatomical variations. Each observed anatomical Primary and secondary pathologies may involve the variation was also documented by photographs. cystic duct11.Spiral cystic duct in 3.15% is in Inclusion criteria included, all patients with acute accordance with previous work where cystic and cholecystitis, chronic cholecystitis, age 16-78 years, any common hepatic duct are spiral and parallel in gender, no co-morbidity and symptomatic gallstones 3.17%.Low confluence of the cystic duct in our work manifesting as biliary colic. Exclusion criteria from was found to be 2% which is comparable with previous study included empyema gall bladder Grade-I,II,III research. Right hepatic duct may divide , similarly left &IVgallbaldder on laparoscopy, diabetes mellitus, hepatic duct may bifurcate.There is a reported incidence hypertention or any other systemic disease patients of cystic ductinsertion in the left and right hepatic ducts. having previous abdominal surgery,bleeding diathesis, Litrature review discloses cystic duct insertion on the patient not fit for general anaesthesia.We undertook a left side of the common hepatic duct.Then anterior, prospective evaluation of cystic duct anatomy and its posterior spiral types of insertion of the cystic ductare

PAKISTAN POSTGRADUATE MEDICAL JOURNAL Vol. 23 No. 4 Oct. – Dec. 2012 115 STUDY OF CYSTIC DUCT ANATOMY AND ITS VARIATIONS USING A LAPAROSCOPE also reported, although our study does not telly up with and P. Sinha, Department of General Surgery, these variations. We have not found parahepatic duct Princess Royal University Hospital, Orpington, insertion into the cystic duct.In our research work we Kent, BR6 8ND, UK, 2008 found absent cystic duct was noted in 0.12%c duct 2. 1. Kelling G. Mittelung zur Benutzung des (length < 5 mm) which is consistent with work donein Oesophagoscops. Allgemeine Medicinsche Central- the past.We did not find cystic duct hypertrophy. Zeitung.1896; 65: 73. Double cystic duct has been found as right hepatic duct 3. 2. Kelling G. Die Tamponade der Bauchhöhle mit emptying into the cystic duct which is consistent with Luft zur Stillung lebensgefährlicher our work. short cystic duct in 8.96%,3.15% double Intestinalblutungen. Münch Med Wochenschr. cystic duct in 1.85%, , accessory cystic duct in 1901; 48: 1480–1483; 1535–1538. 1.78%and adherent cystic duct within the Calot's 4. 3. Kelling G. Untersuchungen über die triangle was demonstrated in 0.12%. Spannungszustände der Bauchwand, der Magen- These findings suggest that accurate preoperative und der Darmwand. Zeitschr Biol. 1903; 44: 161– assessment is very useful in providing a surgical 258. treatment plan in addition to confirming diagnosis12. 5. 4. Jacobaeus HC. Ueber die Möglichkeit die During cholecystectomy, to avoid biliary tree injury, it Zystokopie bei Untersuchung seröser Höhlungen is important to identify the common hepatic-cystic duct anzuwenden. Münch Med Wochenschr.1910; 57: junction. In particular, attention should pay to low 2090–2092. medial insertion of the cystic duct because this 6. 5. Brauer L. Über Laparo- und Thorakoskopie von anatomical variant may lead to misdiagnosis on H.C. Jacobaeus, Privatdozent Stockholm. imaging, and thus affect therapeutic intervention, as was Geleitwort. Beitr Klin Tuberk. 1912; 25: I–II. seen in our first case. 7. 6. Jacobaeus HC. Über Laparo- und Thorakoskopie. A limited literature review of cystic duct anatomy Beitr Klin Tuberk. 1912; 25: 185–354. and with respect to the accidental discovery ofcystic 8. 7. Litynski GS. Highlights in the History of duct variation, it is not the nature of the variation itself Laparoscopy. Frankfurt/Main, Germany: Barbara but rather the existence of the cystic duct variation that Bernert Verlag, 1996. is the most important factor in the prevention of cystic 9. Laparoscopic cholecystectomy poses physical duct injury. Most injuries to the cystic duct usually injury risk to surgeons: analysis of hand technique occur when it runs parallel to the common bile duct and and standing position by Yassar Youssef • Gyusung is encased in a common sheath, so that separation Lee • Carlos Godinez • Erica Sutton • Rosemary V. between the ducts is not readily apparent at surgery. Klein • Ivan M. George • F. Jacob Seagull • Adrian Suspicion should be raised if the cystic duct is of an Park, March 2011 unusually large calibre. 10. Prevalence of variations of the cystic artery in the Sudanese, by M.A. Bakheit, 2009 CONCLUSION 11. Intraoperative Cholangiography during • In conclusion, the cystic duct may be involved in a Laparoscopic Holecystectom Y: What Role? By variety of anatomical variations. Diagnostic Giovanni Tomasello, Vincenzo Davide Palumbo, accuracy relies on a clear understanding of the Provvidenza Damiani, Francesco Damiani, normal anatomy and anatomical variants of the Giuseppe Damiano, Gabriele Spinelli, Filippo cystic duct, and imaging features of calculous Maurizioaccardo, Attilio Ignazio Lo Monte, 2012 disease. Significant variability in cystic duct 12. Bile leaks after videolaproscopic cholecystectomy: anatomy is documented. Surgeonsmust be catious duct of Luschka. Endoscopic treatment in a single about these variations duringLaproscopic centre and brief literature review on current Cholecystectomy. management by Chiara Lo Nigro, Girolamo Geraci, • Accurate knowledge of these variations may help in Antonio Sciuto, Francesco Li Volsi, Carmelo identification of the relevant structures in the right Sciume, Giuseppe Modica, 2012 location at the right time and make very quick 13. Detection of Unsafe Action from Laparoscopic decision to proceed further with safe surgical Cholecystectomy Video by Ashwini Lahane, approach Yelena Yesha, Michael A. Grasso, Anupam Joshi, Adrian E.Park, Jimmy Lo. 2012 REFERENCES 14. The Identification of the Cystic Artery (Sistik Arter 1. Accessory cystic duct identification in laparoscopic Varyasyonlari) by Z. Asli Aktan MD, Figen Govsa cholecystectomy U. Parampalli, S. Helme, G. Asal

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