|Year : 2015 | Volume
| Issue : 3 | Page : 147-150
Anatomic variations of intra- and extra-hepatic biliary system in the Kingdom of Saudi Arabia
Bilal Omar Al-Jiffry
Department of Surgery, College of Medicine, Taif University, Taif, Saudi Arabia
|Date of Web Publication||9-Dec-2015|
Bilal Omar Al-Jiffry
Department of Surgery, College of Medicine, Taif University, PO Box 888, Taif 21947
Source of Support: None, Conflict of Interest: None
Background: Data of the pattern of the anatomical variations from the Middle East are lacking as compared with the literature available elsewhere. The aim of this study was to evaluate the value of routine intraoperative cholangiogram (IOC) to find the pattern of anatomical variations of the biliary tree in patients performing laparoscopic cholecystectomy at Al Hada Military Hospital, Taif, Saudi Arabia. Materials and Methods: Performing routine IOC to all patients undergoing laparoscopic cholecystectomy from May 2010 to December 2011 and examining the cholangiograms by a single hepatobiliary surgeon to record the anatomical patterns. Results: The total number of patients was 177. Normal anatomy was found in 59% of patients. The anatomical variations included; type B (10.7%), type C1 (11.3%), type C2 (6.7), type D1 (4), type D2 (2.2), type E1 (2.8%), type E2 (1.1%), and type F (1.1%). In addition of 1.2% with complex nonrecorded variations. With regards to the cystic duct variations, we found the normal direct cystic duct in 74.6%, type B 14.1, and type C in 11.3. Conclusion: Anatomical variations observed in the present study is nearly similar to that reported in the literature, with two cases of complex biliary anatomy and not described before and further reappearance in other cholangiograms must be kept in mind. However, a higher number of type C cystic duct variations were observed in our study that could cause a higher number of bile duct injuries in laparoscopic cholecystectomy if not recognized.
Keywords: Biliary anatomy, biliary anatomy variation, intra- and extra-biliary anatomy, intraoperative cholangiogram, laparoscopic cholecystectomy
|How to cite this article:|
Al-Jiffry BO. Anatomic variations of intra- and extra-hepatic biliary system in the Kingdom of Saudi Arabia. Saudi J Health Sci 2015;4:147-50
| Introduction|| |
Intraoperative cholangiography (IOC) requires understanding of biliary anatomy and variations. 57% of the population have normal biliary anatomy. The common variants are: One in which there is simultaneous emptying of the right posterior duct, right anterior duct, and left hepatic duct (LHD) into the common hepatic duct (CHD) (11%), a low cystic duct insertion (9%), a medial cystic duct insertion (10–17%) and a parallel course of the cystic duct, and CHD. Data of the pattern of these variations in the Middle East are less.,
We aimed to evaluate the value of routine IOC to find the pattern of anatomical variations of the biliary tree.
| Materials and Methods|| |
As it is the practice to perform routine IOC by the hepatobiliary team at Al Hada Military Hospital, Taif, Saudi Arabia. All patients who underwent cholecystectomy from May 2010 to December 2011 were included in this study. All the IOCs were reviewed by a single hepatobiliary surgeon and compared with the known internationally published anatomical variations. This study was approved by the ethical committee as a retrospective study of the charts and radiology pictures.
The collected data were coded, tabulated, and statistically analyzed using SPSS program (Statistical Package for Social Sciences) software version 18.0 (SPSS Inc., Chicago, USA). Results were expressed as mean ± standard deviation. Descriptive statistics was done with qualitative data as number and percentage. Inferential analyses were done for quantitative variables using McNemar test for agreement between paired categorical data. The level of significance was taken at P < 0.050 is significant, otherwise is nonsignificant. The P value is a statistical measure for the probability that the results observed in a study could have occurred by chance.
| Results|| |
The total number of patients were 177, of which 124 females (70%) and 53 males (30%) with ratio 2.34:1. Typical biliary anatomy (type A) was observed in 59% of the cases (104 patients). The anatomical variations detected by IOC were; type B (10.7), type C1 (11.3%), type C2 (6.7), type D1 (4), type D2 (2.2), type E1 (2.8%), type E2 (1.1%), and type F (1.1%). In our series, we have found two similar cases with very complex intra-hepatic anatomy that do not go with any established variation published elsewhere. With regards to the cystic duct variations, we found the normal direct cystic duct in 74.6%, type B 14.1, and type C in 11.3. [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6] show the different intra-hepatic and cystic duct variations.
|Figure 1: Demonstrates both type A and type B of the normal intra-hepatic biliary anatomy|
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|Figure 2: Demonstrates both type C1 and type C2 of the normal intra-hepatic biliary anatomy|
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|Figure 3: Demonstrates both type D1 and type D2 of the normal intra-hepatic biliary anatomy|
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|Figure 4: Demonstrates both type E1 and type E2 of the normal intra-hepatic biliary anatomy|
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|Figure 5: Demonstrates type F of the normal intra-hepatic biliary anatomy|
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|Figure 6: Demonstrates both type B and type C of the normal cystic duct anatomy|
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| Discussion|| |
Successful hepatobiliary surgery depends on accurate knowledge of the anatomy of extra- and intra-hepatic biliary system. Some surgeons found that IOC during laparoscopic cholecystectomy may have some demerits, however, many surgeons found it accurate and safe method for the detection of choledocholithisis and the anatomic variation of the biliary tree.,, There are many anatomic variations for the intra-hepatic duct.,,,,,,,,,,, Kim et al., found in their study that atypical branching of the right hepatic duct (RHD) was 14%, and it was 8% for the LHD. The two most common variations of the RHD were right anterior and posterior hepatic ducts join together to form the RHD and trifurcation where the RHD is absent and right anterior and posterior hepatic ducts join directly to the confluence with the LHD to form the CHD. The two most common variations in the LHD were segment IV drainage to the left and RHDs., These variations in biliary anatomy are commonly associated with variations in the hepatic arterial system and more specifically portal venous anomalies specially in the right lobe, which is important during liver resections and transplants. Comparing the results of the present study,,,,,,,,,,,, it is clear that there is no significant difference, where normal and aberrant sectoral ductal anatomy include type A (which is the typical ductal anatomy) was 59% in our study versus 57% in literature, type B; triple confluence was found to be 10.7% in this study versus 12% in other studies, type C; ectopic drainage of a right sectoral duct into the CHD, C1; right anterior duct draining into the CHD (11.3% vs. 16%), type C2; right posterior duct draining into the CHD (6.7% vs. 4%), type D, ectopic drainage of a right sectoral duct into the left hepatic ductal system; type D1; right posterior sectoral duct draining into the left hepatic ductal system (4% vs. 5%), type D2; right anterior sectoral duct draining into the left hepatic ductal system (2.2% vs. 1%), type E absence of the hepatic duct confluence (3.9% vs. 3%), and type F (1.1% vs. 1%) in which there is absence of RHD and ectopic drainage of the right posterior duct into the cystic duct. Type F usually represents a difficulty during laparoscopic cholecystectomy, however, the use of IOC would minimize this risk. The technical difficulties, in laparoscopic cholecystectomy in acute cholecystitis increase due to several factors which includes; thickened gallbladder wall and grasping inability, presence of inflammatory process or dense adhesions leading to decreased access to the operative field and the coexistence of anomalies of cystic duct predisposes to increased risk of bile duct injury.,, The most common form of cystic duct union is the type A angular union, however, type B; parallel union and type C; spiral union are also not uncommon., In our study, we find that type A and B are similar to the findings in the literature, however, type C was significantly higher in our study than the international findings (11.3% vs. 5%). A common fibrous sheath around the cystic duct and the CHD are usually found with the long parallel or spiral course of the cystic duct, predisposing to many problems during laparoscopic cholecystectomy especially when it is unknown, these may include; ligation of the cystic duct too close to the common bile duct resulting in stricture of the latter or leaving a long cystic duct remnant, and most seriously, mistaking the cystic duct for the bile duct which may cause inadvertent ligation or transection of the extra-hepatic bile duct. However, in patients with drainage of the cystic duct into the left side of the CHD (type C), it is preferable to leave a long cystic duct remnant instead of dissecting the cystic duct up to the left side of the CHD.
| Conclusion|| |
Anatomical variations observed in the present study is nearly similar to that reported in the literature, with two cases of complex biliary anatomy and not described before, and further reappearance in other cholangiograms must be kept in mind. However, a higher number of type C cystic duct variations were observed in our study; that could cause a higher number of bile duct injuries in laparoscopic cholecystectomy if not recognized.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]