Purpose. Thorough understanding of biliary anatomy is required when performing surgical interventions in the hepatobiliary system. This study describes the anatomical variations of right bile ducts in terms of branching and drainage patterns, and determines their frequency. Methods. We studied 73 samples of cadaveric material, focusing on the relationship of the right anterior and posterior segmental branches, the way they form the right hepatic duct, and the main variations of their drainage pattern. Results. The anatomy of the right hepatic duct was typical in 65.75% of samples. Ectopic drainage of the right anterior duct into the common hepatic duct was found in 15.07% and triple confluence in 9.59%. Ectopic drainage of the right posterior duct into the common hepatic duct was discovered in 2.74% and ectopic drainage of the right posterior duct into the left hepatic duct in 4.11%. Ectopic drainage of the right anterior duct into the left hepatic ductal system and ectopic drainage of the right posterior duct into the cystic duct was found in 1.37%. Conclusion. The branching pattern of the right hepatic duct was atypical in 34.25% of cases. Thus, knowledge of the anatomical variations of the extrahepatic bile ducts is important in many surgical cases. 1. Purpose Anatomic variations of the extrahepatic bile ducts are important during surgical procedures such as laparoscopic cholecystectomy, liver resection (hepatectomy, segmentectomy), and living donor transplantation [1, 2]. It has been shown that the frequency of bile duct injuries occurring during laparoscopic cholecystectomies is twice as high as those occurring during open cholecystectomies [3]. Furthermore, evaluation of the biliary anatomy is essential before hepatic lobectomy or segmentectomy, as inaccurate determination of existing biliary anatomic variations may potentiate ligature or section of aberrant ducts, leading to major complications such as leakage or atrophy of the residual liver [2]. Therefore, it is apparent that thorough knowledge and successful detection and recognition of such anatomic variations can lead to decreased morbidity and mortality rates during hepatobiliary surgery. Although several methods, like CT or MR cholangiograms, have become the modality of choice for noninvasive evaluation of abnormalities of the biliary tract, they are not routinely used in preoperative imaging evaluation of patients undergoing common procedures such as laparoscopic cholecystectomy. Also, several uncommon—and usually more complicated—anatomic variations of the bile duct have been described.
References
[1]
T. L. Huang, Y. F. Cheng, C. L. Chen, T. Y. Chen, and T. Y. Lee, “Variants of the bile ducts: clinical application in the potential donor of living-related hepatic transplantation,” Transplantation Proceedings, vol. 28, no. 3, pp. 1669–1670, 1996.
[2]
K. J. Mortelé and P. R. Ros, “Pictorial essay. Anatomic variants of the biliary tree: MR cholangiographic findings and clinical applications,” American Journal of Roentgenology, vol. 177, no. 2, pp. 389–394, 2001.
[3]
S. M. Strasberg, “Avoidance of biliary injury during laparoscopic chelocystectomy,” Journal of Hepato-Biliary-Pancreatic Surgery, vol. 9, no. 5, pp. 543–547, 2002.
[4]
C. Couinaud, Etudes Anatomiques et Chirugicales, Masson & Cie, Paris, 1957.
[5]
R. Q. Zheng, G. H. Chen, E. J. Xu et al., “Evaluating biliary anatomy and variations in living liver donors by a new technique: three-dimensional contrast-enhanced ultrasonic cholangiography,” Ultrasound in Medicine and Biology, vol. 36, no. 8, pp. 1282–1287, 2010.
[6]
C. Aube, J. J. Tuech, B. Delorme et al., “Contribution of magnetic resonance cholangiography to the anatomic study of bile ducts,” Hepato-Gastroenterology, vol. 51, no. 60, pp. 1600–1604, 2004.
[7]
J. R. Nery, G. P. Fragulidis, T. Scagnelli et al., “Donor biliary variations: an overlooked problem?” Clinical Transplantation, vol. 11, no. 6, pp. 582–587, 1997.
[8]
G. Varotti, G. E. Gondolesi, J. Goldman et al., “Anatomic variations in right liver living donors,” Journal of the American College of Surgeons, vol. 198, no. 4, pp. 577–582, 2004.
[9]
K. K. Lee, S. K. Lee, I. S. Moon, D. G. Kim, and M. D. Lee, “Surgical techniques according to anatomic variations in living donor liver transplantation using the right lobe,” Transplantation Proceedings, vol. 40, no. 8, pp. 2517–2520, 2008.
[10]
M. Ohkubo, M. Nagino, J. Kamiya et al., “Surgical Anatomy of the Bile Ducts at the Hepatic Hilum as Applied to Living Donor Liver Transplantation,” Annals of Surgery, vol. 239, no. 1, pp. 82–86, 2004.
[11]
A. Yoshida, K. Okuda, H. Sakai, H. Kinoshita, and S. Aoyagi, “3D anatomical variations of hepatic vasculature and bile duct for right lateral sector of liver with special reference to transplantation,” Kurume Medical Journal, vol. 55, no. 3-4, pp. 43–53, 2008.
[12]
S. G. Puente and G. C. Bannura, “Radiological anatomy of the biliary tract: variations and congenital abnormalities,” World Journal of Surgery, vol. 7, no. 2, pp. 271–276, 1983.
[13]
Y. F. Cheng, T. L. Huang, C. L. Chen, Y. S. Chen, and T. Y. Lee, “Variations of the intrahepatic bile ducts: application in living related liver transplantation and splitting liver transplantation,” Clinical Transplantation, vol. 11, no. 4, pp. 337–340, 1997.
[14]
J. S. Chen, B. M. Yeh, Z. J. Wang et al., “Concordance of second-order portal venous and biliary tract anatomies on MDCT angiography and MDCT cholangiography,” American Journal of Roentgenology, vol. 184, no. 1, pp. 70–74, 2005.
[15]
D. B. Macdonald, M. A. Haider, K. Khalili et al., “Relationship between vascular and biliary anatomy in living liver donors,” American Journal of Roentgenology, vol. 185, no. 1, pp. 247–252, 2005.
[16]
V. S. Lee, G. R. Morgan, J. C. Lin et al., “Liver transplant donor candidates: associations between vascular and biliary anatomic variants,” Liver Transplantation, vol. 10, no. 8, pp. 1049–1054, 2004.
[17]
M. Kitami, K. Takase, G. Murakami et al., “Types and frequencies of biliary tract variations associated with a major portal venous anomaly: analysis with multi-detector row CT cholangiography,” Radiology, vol. 238, no. 1, pp. 156–166, 2006.
[18]
J. M. Crawford, “Development of the intrahepatic biliary tree,” Seminars in Liver Disease, vol. 22, no. 3, pp. 213–226, 2002.
[19]
H. Bismuth, R. Nakache, and T. Diamond, “Management strategies in resection for hilar cholangiocarcinoma,” Annals of Surgery, vol. 215, no. 1, pp. 31–38, 1992.
[20]
K. A. H. Talpur, A. A. Laghari, S. A. Yousfani, A. M. Malik, A. I. Memon, and S. A. Khan, “Anatomical variations and congenital anomalies of extra hepatic biliary system encountered during laparoscopic cholecystectomy,” Journal of the Pakistan Medical Association, vol. 60, no. 2, pp. 89–93, 2010.
[21]
V. Sharma, V. A. Saraswat, S. S. Baijal, and G. Choudhuri, “Anatomic variations in intrahepatic bile ducts in a north Indian population,” Journal of Gastroenterology and Hepatology, vol. 23, no. 7, pp. e58–e62, 2008.
[22]
L. Skandalakis, Surgical Anatomy and Technique, Springer, New York, NY, USA, 3rd edition, 2009.
[23]
G. S. Gazelle, M. J. Lee, and P. R. Mueller, “Cholangiographic segmental anatomy of the liver,” Radiographics, vol. 14, no. 5, pp. 1005–1013, 1994.