The left and right hepatic duct
openings and the existence of accessory hepatic duct were determined according to intraoperative cholangiography.
During the procedure, the left and right hepatic bile ducts were fused after forming a long segment, and the cystic duct was observed to be draining to the right hepatic duct
(Figure 1) With no significant free fluid in the abdominal cavity and only small bilioma, PTBD was inserted into the right hepatic duct
for temporary diversion of bile.
Intrabiliary rupture occurs in the right hepatic duct
(55-60% cases), left hepatic duct (25-30% cases), hepatic duct junction, common bile duct (CBD), or cystic duct (8-11%); perforation into the gallbladder may be observed in 5-6% of cases.
Bismuth-Corlette perihilar cholangiocarcinoma classification system (1) Type I Involves common hepatic duct only Type II Involves confluence of the primary hepatic ducts Type IIIa Extends from the bifurcation up the right hepatic duct
Type IIIb Extends from the bifurcation up the left hepatic duct Type IV Extends bilaterally from the bifurcation of the common hepatic duct or multifocal involvement Table 3: Contraindications to curative surgery (1) Medical Contraindications A.
Type 1: Normal anatomy; right hepatic duct
and left hepatic duct (LHD) merge to form the common hepatic duct (CHD).
In the present case, an aberrant anatomy of the CD, characterized by the CD draining into the right hepatic duct
(RHD), was found during LC.
They generally drain into the right hepatic duct
or the common hepatic duct, but variations are ordinary .
For example, the left hepatic duct is slender and meets common hepatic duct at nearly a right angel, and there is often a corner when the right posterior segmental duct meets the right hepatic duct
. The two cases mentioned above lead to bile excretion disorder and cholestasis.
Furthermore, Nakamura's operative series report the supraportal RPSBD to be most common in BD variant type I (65%, the classic form where the RPSBD and the anterior sectional BD join to form a single right hepatic duct
), type II (9.2%, the RPSBD joins the confluence, forming trifurcation), and type IV (15.8%, the RPSBD joins the left hepatic duct), whereas the infraportal RPSBD is reported to be most common in type III (8.3%) and that of the combination in type V (1.7%) .
Note that the right hepatic duct
is not visualized due to obstruction.
The "normally" located gallbladder cystic duct entered the common bile duct, whereas the duplicate gallbladder cystic duct entered the right hepatic duct