1 LAPAROSCOPIC STUDY OF ANATOMY OF HEPATOBILIARY TRIANGLE AND ITS VARIATIONS IN PAKISTANI POPULATION THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN ANATOMY BY DR. MIAN AZHAR AHMAD MBBS, MPhil (Anatomy), DTCD SUPERVISOR DR. ASMATULLAH University of the Punjab Lahore, Pakistan. 2 3 4 DEDICATION I dedicate this research thesis to my family, teachers, to the students of past present and future. 5 ACKNOWLEDGEMENTS: All praises to Allah Almighty, the most beneficient, the merciful and to Him belongs everything in the heavens and in universe.All kinds of respects and good deeds to Prophet Muhammad (Peace be upon him) who is forever a torch of guidance and knowledge for the whole humanity.A high gratitude to my supervisor Dr Asmatullah,Unversity of the Punjab,for providing me an inspirational way of life which is beyond student-teacher relationship.He provided me an oppotunity and great assistance to complete this research work. I rank him as my mentor.Prof. Nawab Mohammad Khan,PhD anatomy,helped me in each step with his kind and professionally perfect guidance.He played pivotal role in most cruicial stage of my research work by persistently suggesting me series of corrections and recommendations.His contributions are memorable to give present shape to my thesis.Prof Mohammad Tahir of University of Health Sciences contributed immensely and helped to ensure staying power of my thesis in a very competitive research work niche.My really special regards to Prof Anjum Habib Vohra,Pricipal Postgraduate Medical Instituite,for encouragement and motivation which he imparted to me with his knowledgable words.He supported me in difficult times regarding service structure issues when focus of my concentration was completion of this reasearch work.I have the honour to thank with respect Professor Dr Fouzia Farzana for facilitating me in all possible ways assisting me with technical component of subject.I have learnt lot much from her professionally,ethically and morally.Prof Tokkaya Sultana Abidi contributed technically competent 6 recommendations in this research work.I have deepest regards and respect to Dr.Mian Mazhar Ahmad who is a legendry laparoscopic surgical specialist for extending me great professional guidance to make this thesis so successful.My special thanks to Prof Atiya Khalid,Prof Tassadaq Hussain,Prof Laiq Hussssain,Prof Dr Zafar Ali Chaudhary,Prof Firdos,Prof Dr Sadaqt Ali,Prof Dr Arshad cheema,Prof Dr Majeed chaudhary,Prof Dr Mehmood Ayyaz,Prof Dr Khalid Masood Gondal for providing me the ethical and moral encouragement.I record with gratitude the patient help and support from Dr. Latif Rana for his untiring efforts and to Akbar Ashraf of Shalamar Medical college for his continued effort and help.I acknowledge with respect efforts of Fraz and Adeem Tariq of Punjab University for providing me great secretarial assistence.Its with pleasure to mention here great ethical morale support from Amin Shad and Dr Bushra Sohail,Additional Dean of postgraduate Medical Institute/Lahore General Hospital and Ameerud Din Medical College. Azhar 7 TABLE OF CONTENTS AKNOWLEDGEMENT …………… I LIST OF CONTENTS …………… I LIST OF FIGURES …………… I LIST OF TABLES …………… V SUMMARY …………… 1. INTRODUCTION …………… 1 1.1 An Introduction to laparoscopy surger …………… 18 1.2 History of laparoscopy …………… 19 1.3 Laparoscopic anatomy of the hepatobiliary triangle …………… 20 1.4 Applied aspects of hepatobiliary triangle …………… 21 1.5 Laparoscopic technique vs open surgery …………… 22 1.6 Variations of hepatobiliary triangle …………… 23 1.7 Demerits of laproscopic technique …………… 24 1.8 Exposure of a calot triangle during laparoscopic …………… 24 Cholecystectomy 1.9 Role of diagnostic radiology …………… 25 1.10 Cystic artery …………… 26 1.11 Variations of cystic artery …………… 27 1.11-.A Cystic artery emerging from gastroduodenal artery …………… 27 1.11-B Cystic artery originating from the variant right …………… 28 hepatic artery 1.11-C Cystic artery originating directly from the liver …………… 28 Parenchyma 1.11-D Cystic artery originating from the left hepatic artery …………… 28 1.11 -E Double cystic artery …………… 29 1.12 Cystic duct and gallbladder …………… 29 1.13 Vatiations of cystic duct …………… 30 1.14 Embryology of biliary tree …………… 31 1.15 Lymph nodes relating to hepato-biliary triangle …………… 31 1.16 Arterial sypply to the extrahepatic bile ducts …………… 31 1.17 Aimas and Objectives …………… 33 1. REVIEW OF LITERATURE …………… 34 2.1 Overview …………… 34 2.2 Early Laparoscopy …………… 34 2.3 Evolution of Laparoscopy …………… 35 2.4 Transition to Advanced Laparoscopy …………… 38 2.5 Diagnostic Laparoscopy …………… 38 8 2.6 Litrature survey about cystic duct …………… 39 2.7 Litrature survey about cystic duct …………… 40 3. MATERIAL AND METHODS …………… 44 3.1 Sample size and study population …………… 44 3.2 Place of work and facilities available …………… 44 3.3 Study design and plan …………… 44 3.4 Data collection procedure …………… 44 3.5 Team of laparoscopic surgeons …………… 45 3.6 Laparoscopic equipments …………… 45 3.7 Preoperative investigations …………… 45 3.8 Inclusion criteria …………… 45 3.9 Exclusion criteria …………… 45 3.10 Important considerations …………… 46 3.11 Experimental procedure/Technical considerations …………… 46 3.12 Demographical variables …………… 49 3.13 Dependable variables …………… 49 3.13 Cystic artery …………… 50 3.13-1 Group 1 …………… 50 3.13-2 Group II …………… 50 3.13-3 Group III …………… 50 3.14 Cystic duct …………… 51 3.14 a- Normal cystic duct …………… 51 3.14 b -Absent cystic duct …………… 51 3.14 c- Short cystic duct …………… 51 3.14 d- Double cystic duct …………… 51 3.14 e- Spiral cystic duct …………… 51 3.14 f- Accessory cystic duct …………… 51 3.14 g- Adherent cystic duct …………… 51 3.15 Cystic lymph nodes …………… 51 3.16 Cystic Vein …………… 51 3.17 Catteripller hump or Moynihan hump …………… 51 3.18 Statistical methods …………… 54 4. Results …………… 55 4.1 Variations in patients from Sheikh Zayed Hospital …………… 55 4.2 Variations in patients from Jinnah Hospital …………… 55 4.3 Variations in patients from Lahore General Hospital …………… 56 4.4 Variations in patients from DHQ and Allied Hospital …………… 56 Sahiwal 9 LIST OF FIGURES Figure Nos. Title of photographic evidence of variations of hepatobiliary Page triangles of of 2500 patients in our study. Nos. Figure 3.1 Sketch diagram showing port positions. 47 Figure 4.1 Overview of total patients pooled from all the hospitals (A), 71 respective Data of Sheikh Zayed (B), Jinnah (C), General (D), DHQ allied Sahiwal (E), and Mayo (F) Hospitals. Figure 4.2 Laparoscopic exposure of hepatobilliary triangle in a patient 72 of 34 years female in Pakistani population. Figure 4.3 Photograph illustrating cystic artery outside hepatobilliary 74 triangle in a patient of 54 years female.as seen with the help of laparoscope. Figure 4.4 Photograp indicating abnormal location of cystic artery 75 unprecedented posterior and superior to cystic lymph node within hepatobiliary triangle in a patient of 53years female. as seen with the help of laparoscope. Figure 4.5 Photographic evidence explaining unusual position of cystic artery anterior to cystic lymph node in hepatobilliary triangle in a patient of 58 female.as seen with the help of laparoscope. Note: 1) Cystic artery, 2) Cystic lymph node, 3) Cystic duct. Figure 4.6 Photographic evidence explaining variation in the form of excessive fat around hepatobilliary triangle in a patient of 32years female. as seen with the help of laparoscope- characteristic feature of female patients. Figure 4.7 Unique notification of this research work, double cystic artery, A photograph showing variation in the shape of double cystic artery within hepatobiliary triangle in a patient of 33years female. as observed with the help of laparoscope. Figure 4.8 Variation of cystic artery documented.Photographic evidence explaining cystic artery arising from common hepatic artery within hepatobiliary triangle in a patient of 49years female. as observed with the help of laparoscope. Figure 4.9 Variation of cystic artery notiied here. Photograph explaining cystic artery arising from right hepatic artery within hepatobiliary triangle in a patient of 45years female.as documented with the help of a laparoscope. Figure 4.10 Variableanatomy of cystic artery documented here. Photographic evidence explaining cystic artery arising from common hepatic artery making Catterpiller within hepatobiliary triangle in a patient of 65years male. As documented with help of a laparoscope. Figure 4.11 Variation of cystic artery notified as Catterpiller formation. Photographic evidence of cystic artery arising from right 10 hepatic artery making catterpiller within hepatobiliary triangle in a patient of 36years female as documented with the help of laparoscope. Figure 4.12 Photograph explaining normal cystic duct in 88% patients in ous study as seen using a microscope laparoscope within hepatobiliary triangle in a patient of 39years female. Figure 4.13 Variable anatomy of cystic duct documented here. Photograph showing accessory cystic duct in a patient of 41years female as observed using a laparoscope. Figure 4.14 Cystic duct variation documentedhere.Pho tograph illustrating laparoscopic exposure of low origen-cystic duct in a patient of 46years female as documented through a laparoscope. Figure 4.15 Anatomical variation of cystic duct duct illustrated here. Photograph ilolustrating laparoscopic exposure of short -cystic duct presented within the Calot triangle in a patient of 44years female as documented using a laparoscope. Figure 4.16 Anatomical variation of cystic duct duct illustrated here. Photograph illustrating laparoscopic exposure of long cystic duct presented within the iliary epatobh Calot triangle in a patient of 43years female Figure 4.17 Cystic duct variation documented here.Photograph explaining laparoscopic exposure of high origen cystic duct presented within the Calot triangle in a 45-year-old woman. Figure 4.18 Anatomical variation of cystic duct duct illustrated here. Photograph illustrating laparoscopic exposure of double cystic duct as documented using a laparosc in a 57-year-old man.The termination is presented within the Calot triangleope.