
==== Front
Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00926-X
10.1016/j.ijscr.2024.110145
110145
Case Report
Bile duct injury following laparoscopic cholecystectomy in a patient with a trifurcated hepatic duct: A case report
Luitel Prajjwol a
Paudel Sujan a
Thapaliya Ishwor ishworthapaliya68560@gmail.com
a⁎
Dhungana Shrawan a
Thapa Neeraj b
Devkota Shishir c
a Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
b Nepal Medical College, Kathmandu, Nepal
c Department of General Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
⁎ Corresponding author. ishworthapaliya68560@gmail.com
10 8 2024
10 2024
10 8 2024
123 11014510 6 2024
1 8 2024
8 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

Iatrogenic bile duct injury is a serious complication of laparoscopic cholecystectomy, often due to misinterpretation of biliary tree anatomy. Anatomical variations, patient condition, gallbladder pathology, and surgeon-related factors are key risk factors for bile duct injury.

Case presentation

A 68-year-old male with a history of hypertension and type 2 diabetes mellitus underwent Laparoscopic cholecystectomy for symptomatic gallstones. One-month post-surgery, he developed right upper quadrant pain, jaundice, and elevated liver enzymes. Magnetic resonance cholangiopancreatography (MRCP) showed a hilar confluence stricture affecting the right posterior and left hepatic ducts, with mild-to-moderate dilation of upstream intrahepatic bile ducts.

Clinical discussion

Trifurcation of the hepatic duct is a rare but clinically significant anatomical variation that can predispose patients to common bile duct injuries. Preoperative MRCP can identify such variations, aiding in surgical planning. However, intraoperative recognition and management of these anatomical differences are crucial to prevent bile duct injuries. This is particularly important in low-resource settings where routine preoperative imaging may not be feasible.

Conclusion

Accurate intraoperative identification of biliary tree anatomical variations is essential to prevent iatrogenic injuries during surgery. Preoperative imaging, when available, can provide valuable information to assist in surgical planning. Additionally, the use of intra-operative cholangiogram (IOC) should be considered to help identify and manage anatomical variations, thereby reducing the risk of bile duct injuries.

Highlights

• Knowledge of anatomical variations, like trifurcation, is crucial to avoid bile duct injury in hepatic and biliary procedures.

• MRCP revealed hilar stricture and bile duct dilation.

• Interventions (ERCP, PTBD, Roux-en-Y) normalized liver enzymes within a week.

• Trifurcation may increase risks of bile duct injuries, strictures, biliary cirrhosis, and postoperative complications.

• MRCP is the preferred noninvasive method for biliary tract evaluation.

Keywords

Anatomic variation
Bile ducts
Magnetic resonance cholangiopancreatography
==== Body
pmc1 Introduction

Laparoscopic cholecystectomy (LC) is the gold standard surgical treatment for symptomatic gallstones [1]. Bile duct injury (BDI) is a serious complication of LC leading to significant morbidity and mortality, with an annual incidence of 0.18–0.23 % in large-volume audits [2,3]. These injuries can lead to severe clinical consequences, including bile leakage, biliary peritonitis, cholangitis, and secondary biliary cirrhosis. Long-term complications may involve recurrent strictures and the need for complex surgical repairs. The anatomy of the biliary tree is complex, featuring various intrahepatic and extrahepatic anatomical variations [4]. Normally, the right and left hepatic ducts join to form the common hepatic duct in the porta hepatis. The common hepatic duct is joined by the cystic duct from the gallbladder to form the common bile duct (CBD) [5].

Typical biliary anatomy has been reported to occur in 55–67 % of population studies [6,7]. Trifurcation of the hepatic duct involves simultaneous emptying of the right posterior, right anterior, and left hepatic ducts into the 3 common hepatic ducts. It is considered a rare anatomical variant with the incidence rate varying from 5 to 21.5 % and is a risk factor for BDI [[7], [8], [9]]. Imaging studies to evaluate bile duct abnormalities include endoscopic retrograde cholangiography (ERCP), magnetic resonance cholangiopancreatography (MRCP), and DIC-CT. MRCP and DIC-CT are preferred over ERCP because they are minimally invasive [10].

Here, we present a case adhering to SCARE 2023 guidelines of iatrogenic BDI in a patient with trifurcation of the hepatic duct that was successfully managed with Roux-en-Y hepaticojejunostomy [11].

2 Case presentation

A 68-year-old male with Body Mass Index (BMI) of 28.3 kg/m2presented with complaints of pain in the right upper abdomen, which was of sudden onset, colicky nature, episodic, with each episode lasting for 3–4 h associated with nausea and vomiting. The patient was diagnosed with symptomatic cholelithiasis and underwent laparoscopic cholecystectomy. An operative cholangiogram was not performed; however, the operation proceeded uneventfully. The patient remained asymptomatic for one month but presented with pain in the right upper abdomen, which was dull aching, continuous yellowish discoloration of the eyes, and generalized itching of the body without a history of fever, vomiting, and significant weight loss. He had a history of controlled hypertension and type 2 diabetes mellitus. He was a non-smoker and had an ASA score of 2. He had no other surgical history and no significant family medical history.

Laboratory investigations revealed elevated total bilirubin; 4.8 mg/dl (reference range:0.3–1.2), direct bilirubin; 3.4 mg/dl (reference range:0–0.3), SGPT/ALT; 242 U/l (reference range:12–78), SGOT/AST; 121 U/l (reference range:10–35), ALP; 397 U/l (reference range:20–115) and GGT; 694 U/l (reference range:0–50). MRCP (done at second day of presentation) revealed choledocholithiasis with prominent CBD and stricture at the hilar confluence affecting the right posterior and left hepatic ducts, with mild to moderate dilation of the upstream bilateral IHBDs (Fig. 1). CT tomography revealed abrupt narrowing of the common hepatic duct at the primary confluence with moderate dilation of the intrahepatic bile duct, likely of benign stricture, probably Strassberg classification type E3 without associated vascular injury.Fig. 1 Coronal MRCP image showing trifurcation anomaly in the biliary tree, characterized by distinct right anterior, right posterior, and left hepatic ducts converging to form the primary confluence with hilar confluence stricture. Additionally, it shows mild-to-moderate dilation of upstream intrahepatic bile ducts.

Fig. 1

Endoscopic retrograde cholangiopancreatography (ERCP) was performed, encompassing the placement of an 8 French plastic stent in the right hepatic duct to bypass the stricture with the extraction of a common bile duct (CBD) stone. He remained relatively well immediately after and then presented at the hospital on two occasions within six months, experiencing recurring symptoms of jaundice and abdominal pain. Stent blockage was suspected during each visit, and the patient underwent right-sided percutaneous transhepatic biliary drainage (PTBD) with a 10 French locking pigtail catheter during both admissions. Subsequent to PTBD, T-tube cholangiography was performed on second presentation with recurrence of symptoms through open surgical approach (Fig. 2), revealing a trifurcated hepatic duct with hilar stricture. Following three months of PTBD, the patient was re-explored, and Roux-en-Y hepaticojejunostomy was performed to address the identified hepatic duct abnormalities (Fig. 3). All liver function parameters returned to normal within one week. At follow-up of 12 months, there were no complications, especially in the biliary tree.Fig. 2 T-tube cholangiography image demonstrating an abrupt cut-off at the trifurcated duct beyond the confluence. The image reveals the distinct separation of the right posterior, right anterior, and left hepatic ducts (third and fourth image) with no contrast flow beyond the point of confluence, indicating a stricture.

Fig. 2

Fig. 3 Intraoperative image displaying tubes positioned in situ within the three hepatic ducts. The tubes are placed as follows: (1) right posterior duct, (2) right anterior duct, and (3) left hepatic duct.

Fig. 3

3 Discussion

The etiology of biliary tree abnormalities remains unclear. The current findings suggest that disruption in early human embryogenesis may limit the regression of primitive duct structures, although the exact cause of these anomalies is unknown [12]. Trifurcation of the hepatic duct is a rare anatomical variant with the incidence rate varying from 5 to 21.5 % [7,9]. Misidentification of such variations can increase the risk of BDI during biliary surgeries. The number of BDI cases has increased with the adoption of laparoscopic cholecystectomy as a treatment for symptomatic cholelithiasis [13,14]. Patients with intraoperative BDI may present with unexpected fever, abdominal pain, abdominal distension, nausea, and malaise after the procedure. Bile leakage can lead to abscess formation and peritonitis. Moreover, BDI can be fatal if it leads to sepsis or liver failure [1].

More than three-fourths of BDI are not recognized during surgery, and late presentation even after 90 days has been reported [15]. Similarly, in our case, the patient presented one month after LC with symptoms suggestive of obstructive jaundice. We initially suspected retained choledocholithiasis and performed an MRCP and a CT scan, which revealed a Strassberg E3 biliary stricture in addition to choledocholithiasis. MRCP is a non-invasive imaging technique that provides detailed visualization of the biliary tree, making it valuable for identifying anatomical variations preoperatively. The advantages of MRCP include its high accuracy, non-invasiveness, and ability to delineate biliary and pancreatic ductal systems without the need for contrast agents. However, its limitations include high cost, limited availability in low-resource settings, and potential issues with image quality in patients with metallic implants or severe obesity [7]. In resource-limited settings, optimizing preoperative evaluations can involve a combination of cost-effective imaging modalities and clinical judgment. Ultrasound, although less detailed than MRCP, can be used as an initial screening tool. Intraoperative cholangiogram (IOC) remains a valuable technique for real-time identification of biliary anatomy during surgery. In this case, the use of an IOC might have helped identify the trifurcation anomaly and prevent the subsequent BDI. The routine use of IOC in LC, especially in cases with suspected anatomical variations, should be considered to improve surgical outcomes and reduce the incidence of iatrogenic injuries.

Initially, we opted for ERCP with removal of the CBD stone and placement of the stent; however, with recurrence, we proceeded with PTBD. Following the recurrence of symptoms and confirmation of intrahepatic duct dilatation and partial stricture of the distal two-thirds of the common bile duct on T-tube cholangiogram, Roux-en-Y hepaticojejunostomy was performed. This approach has been reported to result in the resolution of symptoms in prior cases involving the management of bile duct strictures due to hepatic duct trifurcation, with successful Roux-en-Y anastomosis with the jejunum [16].

4 Conclusion

To minimize the risk of bile duct injuries during laparoscopic cholecystectomy, it is essential to have a thorough understanding of biliary anatomy, including potential anatomical variations. Routine use of MRCP is advised in cases where anatomical variations are suspected or in patients with complex biliary pathology although its routine adoption in all settings is limited by its expense and availability. Additionally, intraoperative cholangiogram should be considered as a standard practice to provide real-time visualization of the biliary tree. Additionally, healthcare practitioners should promptly refer or transfer patients to a tertiary medical facility, as addressing these injuries typically requires the expertise of a skilled, multidisciplinary team (including interventional radiology, gastroenterology, and hepatobiliary surgery).

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Since this is a case report, our Institutional Review Board has waived the requirement for ethical approval.

Funding

No funding received.

Author contribution

P.L. formulated the original manuscript. P.L., S.P., I.T., S.D., and N.T. reviewed and edited the manuscript. S.D. supervised the case. All the authors reviewed and approved the final version of the manuscript.

Guarantor

Prajjwol Luitel

Research registration number

None.

Conflict of interest statement

Authors have no conflict of interest to declare.
==== Refs
References

1 Suzuki T, Asahi Y, Sawada A, Umemoto K, Kina M, Shinohara M, et al. Laparoscopic cholecystectomy for a cholelithiasis patient with an aberrant biliary duct of B5: a case report. [cited 2023 Dec 13]; Available from: doi:10.1186/s40792-020-00981-z7.
2 Barrett M, Asbun HJ, Chien HL, Brunt LM, Telem DA. Bile duct injury and morbidity following cholecystectomy: a need for improvement. Surg Endosc [Internet]. 2018 Apr 1 [cited 2023 Dec 13];32(4):1683–8. Available from: https://pubmed.ncbi.nlm.nih.gov/28916877/.
3 Pesce A, Portale TR, Minutolo V, Scilletta R, Li Destri G, Puleo S. Bile duct injury during laparoscopic cholecystectomy without intraoperative cholangiography: a retrospective study on 1,100 selected patients. Dig Surg [Internet]. 2012 Nov [cited 2023 Aug 22];29(4):310–4. Available from: https://pubmed.ncbi.nlm.nih.gov/22986956/.
4 Sarawagi R, Sundar S, Raghuvanshi S, Gupta SK, Jayaraman G. Common and Uncommon Anatomical Variants of Intrahepatic Bile Ducts in Magnetic Resonance Cholangiopancreatography and its Clinical Implication. Polish J Radiol [Internet]. 2016 May 26 [cited 2023 Oct 31];81:250. Available from: /pmc/articles/PMC4886616/.
5 The Biliary Tree | Radiology Key [Internet]. [cited Available from: https://radiologykey.com/the-biliary-tree/ 2023 Oct 31
6 Mortelé KJ, Ros PR. Pictorial essay. Anatomic variants of the biliary tree: MR cholangiographic findings and clinical applications. Am J Roentgenol [Internet]. 2001 Nov 23 [cited 2023 Aug 22];177(2):389–94. Available from: 10.2214/ajr.177.2.1770389.
7 Sureka B, Bansal K, Patidar Y, Arora A. Magnetic resonance cholangiographic evaluation of intrahepatic and extrahepatic bile duct variations. Indian J Radiol Imaging [Internet]. 2016 Feb 1 [cited 2023 Oct 31];26(1):22. Available from: /pmc/articles/PMC4813070/ 8.
8 Evaluation of biliary tree anatomy and its variation. [cited 2023 Dec 13]; Available from: doi:10.5115/acb.19.177.
9 Taghavi1 SA, Niknam R, Alavi SE, Ejtehadi F, Sivandzadeh GR, Eshraghian A. Anatomical variations of the biliary tree found with endoscopic retrograde Cholagiopancreatography in a referral Center in Southern Iran. Middle East J Dig Dis [Internet]. 2017 Sep 30 [cited 2023 Dec 13];9(4):201. (Available from: /pmc/articles/PMC5726332/).
10 Persson A, Dahlström N, Smedby Ö, Brismar TB. Three-dimensional drip infusion CT cholangiography in patients with suspected obstructive biliary disease: a retrospective analysis of feasibility and adverse reaction to contrast material. BMC Med Imaging [Internet]. 2006 Apr 22 [cited 2023 Dec 13];6:1. Available from: /pmc/articles/PMC1475834/.
11 Keplinger KM, Bloomston M. Anatomy and embryology of the biliary tract. Surg Clin North Am [Internet]. 2014 [cited 2023 Dec 13];94(2):203–17. Available from: https://pubmed.ncbi.nlm.nih.gov/24679417/.
12 Sohrabi C. Mathew G. Maria N. Kerwan A. Franchi T. Agha R.A. The SCARE 2023 guideline: updating consensus surgical CAse REport (SCARE) guidelines Int J Surg Lond Engl. 109 5 2023 1136
13 Alseidi A, Wiebusch A, Smith RK, Helton WS. Bile Duct Injury. Common Probl Acute Care Surg [Internet]. 2023 Jul 31 [cited 2023 Dec 13];273–92. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546703/ 9.
14 Pesce A, Portale TR, Minutolo V, Scilletta R, Li Destri G, Puleo S. Bile duct injury during laparoscopic cholecystectomy without intraoperative cholangiography: a retrospective study on 1,100 selected patients. Dig Surg [Internet]. 2012 Nov [cited 2023 Dec 13];29(4):310–4. Available from: https://pubmed.ncbi.nlm.nih.gov/22986956/.
15 Hite M, Chung C, Lancaster W. Surgical management of iatrogenic bile duct injury in patients with atypical ductal anatomy. Am Surg [Internet]. 2020 Feb 1 [cited 2023 Dec 13];86(2):E64–6. Available from: 10.1177/000313482008600206?journalCode=asua.
16 Moossa AR, Easter DW, Casola G, Agostino HD’. Laparoscopic Injuries to the Bile Duct A Causefor Concern.
