Clinical reappraisal of vasculobiliary anatomy relevant to laparoscopic cholecystectomy

Abstract

Background: Laparoscopic cholecystectomy (LC) has many advantages as compared to open cholecystectomy. However, vasculobiliary injuries still continue to be a matter of concern despite advances in laparoscopic techniques. Misidentification and misperception of vasculobiliary structures is considered to be a pivotal factor leading to injuries. Although many studies since time immemorial have stressed on the importance of anatomy, an insight into laparoscopic anatomy is what essentially constitutes the need of the hour.

Objective: To assess the frequency and the relevance of anatomical variations of extrahepatic biliary system in patients undergoing LC.

Materials and methods: The present study is an observational study performed for a period of 2 years from August 2014 to August 2016. It included all diagnosed patients of cholelithiasis undergoing routine LC performed by a single surgeon by achieving a critical view of safety. During dissection, vascular and ductal anomalies were noted and assessed for their relevance in LC.

Results: Seven hundred forty cases of cholelithiasis, irrespective of pathology, comprising 280 (37.83%) men and 460 (62.16%) females with a mean age of 39.85 ± 18.82 years were included in the study. Photodocumentation and operative recordings were available in 93% of cases. Operative findings revealed 197 (26.62%) vascular anomalies and 90 (12.16%) ductal anomalies. A single cystic artery was seen in 340 cases, and a normal cystic duct was seen in 650 cases. Variations in ductal anatomy were fewer than variations in vascular anatomy.

Conclusion: Extra-biliary anatomy relevant to LC is unpredictable and varies from patient to patient. Vascular anomalies are more frequent than the ductal anomalies, and surgeon should be alert regarding their presence.

Figure 1

Single cystic duct. One end is entering the gallbladder and the other end is entering the common bile duct

Figure 2

Short cystic duct with stones

Figure 3

Subvesical duct draining into the biliary ductal system in close relationship to the gallbladder

Figure 4

Diagram showing the cholecystohepatic duct

Figure 5

Classical single cystic artery

Figure 6

Double cystic artery

Figure 7

Cystic artery arising from caterpillar hump (right hepatic artery)

Figure 8

Two vessels (anterior and posterior)

Figure 9

Cystic artery originating from gastroduodenal artery

Figure 10

Cystic artery originating from variant right hepatic artery

Figure 11

Vessel seen during posterior dissection