Skip to main content
SpringerLink
Log in

Variations in biliary ductal and hepatic vascular anatomy and their relevance to the surgical management of choledochal cysts

  • Original Article
  • Published:
Pediatric Surgery International Aims and scope Submit manuscript

Abstract

Purpose

An aberrant biliary ductal and vascular anatomy presents a technical challenge for choledochal cyst (CDC) surgery. Mismanagement may have unfavourable implications. This study highlights the spectrum, approach to their identification and management.

Methods

Forty of 117 (34 %) cases were identified to have an aberrant biliary ductal (n = 17) or arterial (n = 26) anatomy; 3 had both. The pancreaticobiliary anatomy was defined by an intraoperative cholangiogram (IOC) before January 2005 and a preoperative magnetic resonance cholangiopancreatogram (MRCP) subsequently.

Results

IOC missed 3 of 4 aberrant biliary ducts, while an MRCP accurately delineated 10 of 13 aberrant bile ducts. The significant biliary anomalies were: an aberrant right sectoral/segmental duct joining the common hepatic duct (CHD) or the cyst itself (n = 14), cystic duct (n = 1) and cystic duct–CHD junction (n = 1). The aberrant duct was incorporated into the biliary-enteric anastomosis (B-EA) by: (i) double ostia B-EA (n = 1), (ii) ductoplasty with single ostium B-EA for aberrant duct and CHD (n = 2), and (iii) transection of the CHD/cyst distal to the aberrant duct orifice with a single ostium B-EA (n = 13). The arterial anomalies were (i) replaced or accessory right hepatic artery (RHA) (n = 11) and (ii) RHA crossing anterior to the cyst (n = 15), which was repositioned posterior to the B-EA.

Conclusion

It is important to consciously look for, appropriately identify and manage aberrant biliovascular anatomy. MRCP facilitates accurate preoperative delineation of aberrant duct anatomy. All major aberrant ducts need to be incorporated into the B-EA and aberrant arteries should not be ligated.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Ohkuba M, Nagino M, Kamiya J, Yuasa N, Oda K, Arai T, Nishio H, Nimura Y (2004) Surgical anatomy of the bile ducts at the hepatic hilum as applied to live donor liver transplantation. Ann Surg 239:82–86

    Article  Google Scholar 

  2. Marcos A, Ham JM, Fisher RA, Olzinski AT, Posner MP (2000) Surgical management of anatomical variation of right lobe in living donor liver transplantation. Ann Surg 231:824–831

    Article  PubMed  CAS  Google Scholar 

  3. Deshpande RR, Heaton ND, Rela M (2002) Surgical anatomy of segmental liver transplantation. BJS 89:1078–1088

    Article  CAS  Google Scholar 

  4. Larobina M, Nottle PD (2005) Extrahepatic biliary anatomy at laparoscopic cholecystectomy: is aberrant anatomy important? ANZ J Surg 75:392–395

    Article  PubMed  Google Scholar 

  5. Hirao K, Miyazaki A, Fujimoto T, Isomoto I, Hiyashi K (2000) Evaluation of aberrant bile ducts before laparoscopic cholecystectomy: helical CT cholangiography versus MR cholangiography. AJR 175:713–720

    Article  PubMed  CAS  Google Scholar 

  6. Izuishi K, Toyama Y, Nakano S, Goda F, Usuki H, Masaki T, Macta H (2005) Preoperative assessment of the aberrant bile duct using multislice computed tomography cholangiography. Am J Surg 189:53–55

    Article  PubMed  Google Scholar 

  7. Blumgart LH, Hann LE (2000) Surgical and radiological anatomy of the liver and biliary tree. In: Blumgart LH, Fong Y (eds) Surgery of the liver and biliary tract, vol 1, 3rd edn. W. B. Saunders Company Ltd, Edinburgh, pp 13–34

    Google Scholar 

  8. Hiatt JR, Gabbay J, Busuttil RW (1994) Surgical anatomy of the hepatic arteries in 1,000 cases. Ann Surg 220:50–52

    Article  PubMed  CAS  Google Scholar 

  9. Hill R, Parsons C, Farrant P, Sellars M, Davenport M (2011) Intrahepatic duct dilatation in type 4 choledochal malformation: pressure related, postoperative resolution. J Pediatr Surg 46:299–303

    Article  PubMed  Google Scholar 

  10. Sarkari A, Gambhir S, Kumar A, Saxena R, Kapoor VK, Sikora SS (2004) Evaluation of bilioenteric anastomosis using quantitative hepatobiliary scintigraphy. Hepatogastroenterology 51:1267–1270

    PubMed  CAS  Google Scholar 

  11. Todani T, Watanabe Y, Toki A, Morotomi Y (2003) Classification of congenital biliary cystic disease: special reference to type Ic and type IVA cysts with primary ductal stricture. J Hepatobiliary Pancreat Surg 10:340–344

    Article  PubMed  Google Scholar 

  12. Todani T, Watanabe Y, Narusue M, Tabuchi K, Okajima K et al (1977) Congenital bile duct cyst: its classification, operative procedures and review of 37 cases including cancer arising from choledochal cyst. Am J Surg 134:263–269

    Article  PubMed  CAS  Google Scholar 

  13. Todani T, Watanabe Y, Toki A, Ogura K, Wang Z-Q (1998) Co-existing biliary anomalies and anatomical variants in choledochal cysts. BJS 85:760–763

    Article  CAS  Google Scholar 

  14. Narasimhan KL, Chowdhary SK, Rao KLN (2001) Management of accessory hepatic ducts in choledochal cysts. J Pediatr Surg 36:1092–1093

    Article  PubMed  CAS  Google Scholar 

  15. Dong Q, Jiang B, Zhang H, Jiang Z, Lu H, Yang C, Cheng Y, Hao X (2006) Management strategy for congenital choledochal cyst with co-existing intrahepatic dilatation and aberrant bile duct as well as other complicated biliary anomalies. Yonsei Med J 47:826–832

    Article  PubMed  Google Scholar 

  16. Saito T, Hishiki T, Terui K, Sato Y, Mitsunaga T, Terui E, Nakata M, Takenouchi A, Matsuura G, Yahata E, Ohno S, Sato H, Yanagawa N, Masuda Y, Yoshida H (2011) Use of preoperative, 3-dimensional magnetic cholangiopancreaticography in pediatric choledochal cysts. Surgery 149:569–575

    Article  PubMed  CAS  Google Scholar 

  17. Schmidt SC, Settmacher U, Langrehr JM, Neuhaus P (2004) Management and outcome of patients with combined bile duct and hepatic arterial injuries after laparoscopic cholecystectomy. Surgery 135(6):613–618

    Article  PubMed  Google Scholar 

  18. Michels NA (1962) Newer anatomy of the liver and its variant blood supply and collateral circulation. Am J Surg 112:337–347

    Article  Google Scholar 

  19. Nelson TM, Pollak R, Jonasson O, Abcarian H (1988) Anatomic variants of the coeliac, superior mesenteric and inferior mesenteric arteries and their clinical relevance. Clin Anat 1:75–91

    Article  Google Scholar 

Download references

Acknowledgments

Dr. Basant Kumar and Dr. Vijay Upadhyaya assisted in performing the surgical procedure in cases operated since 2009. Dr. Zafar Neyaz gave useful inputs about the technical details of MRCP. Dr. S Gambhir gave useful inputs about the technical details of hepatobiliary scintigraphy. Mr. Anil Kumar prepared the line diagrams.

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. Department of Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226014, India

    Richa Lal

  2. Department of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226014, India

    Anu Behari, Ranjit Hari Vijaya Hari, Sadiq S. Sikora & Vinay Kumar Kapoor

  3. Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226014, India

    Surender Kumar Yachha

Authors
  1. Richa Lal
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Anu Behari
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ranjit Hari Vijaya Hari
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sadiq S. Sikora
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Surender Kumar Yachha
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Vinay Kumar Kapoor
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Richa Lal.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Lal, R., Behari, A., Hari, R.H.V. et al. Variations in biliary ductal and hepatic vascular anatomy and their relevance to the surgical management of choledochal cysts. Pediatr Surg Int 29, 777–786 (2013). https://doi.org/10.1007/s00383-013-3333-5

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00383-013-3333-5

Keywords

Search

Navigation