A Case Report of Double Cystic Duct During Laparoscopic Cholecystectomy in Patient with Acute on Chronic Calculus Cholecystitis

INTRODUCTION

The biliary tree anatomy is fairly simple. Laparoscopic surgery on the gall bladder is one of the commonest performed surgeries. Currently, due to the improvements in imaging and availability of cholangiogram services round the clock, it is performed even in an emergency setting. However, the biliary tree has one of the most variable anatomies, most of them congenital.^[1]

One of the rarest anomalies is the duplication of the cystic duct in the presence of a single gall bladder. Unfortunately, there is no preoperative imaging that can identify this anomaly. It is only during the surgery that this anomaly can be identified. Unfortunately, diagnosis is usually established during surgery.^[1] Only 18 cases have been reported currently in the literature.^[2–17] We report a case of duplication of the cystic duct encountered during laparoscopic cholecystectomy at our hospital.

CASE REPORT

A 56-year-old male patient with diabetes and hypertension presented with an acute attack of right hypochondriac pain of 5 days’ duration. The patient had had similar attacks over a period of 1 year and had been medically managed. There was no fever or jaundice. No significant surgical history was noted.

On examination, the middle-aged male who is moderately built and nourished. Was conscious, co-operative, and well oriented, to time, place, and person. No pallor, icterus, clubbing, cyanosis, generalised lymphadenopathy, or pitting pedal oedema. He was afebrile. Vitals were stable. The abdomen was soft with mild tenderness in the right hypochondrium. No mass palpable. Electrocardiography and echocardiography were within normal range. There was leucocytosis with neutrophilia. All of the other investigations, including the liver function test, renal function test, and electrolytes, were found to be normal. An emergency ultrasound was done, which showed multiple gallstones, the largest of which was 7.2 mm in size. No other investigations were performed. Owing to the rise in leucocyte count and the diabetic status of the patient, it was decided to take up the patient for an emergency cholecystectomy. The patient was started on piperacillin tazobactam intravenously. The patient was subjected for a laparoscopic cholecystectomy under general anaesthesia. The standard 4-port technique was adopted with the 10 mm umbilical port for the camera, a 10 mm subxiphisternal port, and two 5 mm ports: one at the level of the fundus of the gallbladder and the other 10 cm from the costal margin in the anterior axillary line. After dissecting the cystic plate, the triangle of Calot was delineated, and a critical angle of safety was created. However, on scrutiny, a tubular structure seemed to be arising from the gall bladder and communicating to the part of the hepatic duct proximal to the opening of the cystic duct, which had been dissected [Figure 1].

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Figure 1:

Accessory cystic duct entering into common hepatic duct.

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Due to the unusual anatomy encountered, an on-table cholangiogram was planned, but could not be completed because of technical issues. A careful dissection of the accessory duct was carried out, tracing it right to the common aquatic. Once safety was visually established, the cystic ducts were clipped using titanium clips, and the gall bladder was safely removed. On examining the specimen of the gallbladder, it was indeed confirmed that there were two cystic ducts, each opening separately into the gallbladder [Figure 2].

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Figure 2:

Artery forceps demonstrating entering the gallbladder and a normal and an accessory cystic duct.

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A 28 French drainage tube was placed in the Morrison’s pouch. The patient had an uneventful 48 hours, after which the drain was removed and the patient was discharged. Follow-up 1 week after the surgery and 3 weeks after the surgery included liver function test and an ultrasound, and both were found to be normal.

DISCUSSION

Variations of the cystic duct are very common; however, duplication of the cystic duct in the presence of a single gall bladder is a very rare occurrence.^[11]

Previous studies have reported variations in cystic duct anatomy as three types:

1. Y type: The normal cystic duct and accessory cystic duct meet and form a single duct.

2. Trabecular type: Here the duplicated duct directly enters the liver.

3. H type: The accessory duct can join the right and left hepatic ducts or the common hepatic ducts.

In our patient, both the normal cystic duct and the accessory system duct were originating from a single gall. The normal cystic duct was draining into the common bile duct, whereas the accessory one was draining directly into the common hepatic duct. This fact could not be confirmed by the intraoperative cholangiogram due to technical issues; however, meticulous dissection by the experienced surgeon could delineate both the cystic ducts; however. After reviewing the literature available and in hindsight, we would have converted the patient for an open cholecystectomy in order to perform the on-table cholangiogram. Even though limited by the lack of availability of the laparoscopic cholangiography equipment, meticulous dissection does help, and it is imperative for the laparoscopic surgeon to identify duplication of the cystic duct in order to prevent postoperative morbidity.

CONCLUSION

Duplication of cystic duct is an extremely rare anomaly. Laparoscopic surgeons should be aware of this anomaly, identify it to avoid postoperative morbidity.