The patient is a 79-year-old white man who had a laparoscopic converted to open cholecystectomy performed approximately 3 weeks before transfer to our facility. Details of the original operation noted a gangrenous perforated gallbladder requiring an open conversion. The cholecystectomy was performed using a retrograde fundus-down approach, with inability to obtain the critical view. A tubular structure, thought to be a duct of Luschka, was also identified and ligated in addition to the cystic artery and duct. A single drain was placed, and the procedure was completed in an otherwise standard fashion.\nPostoperatively, the patient had persistent high-output bilious drainage. He was discharged on postoperative Day 6 with a drain in place. He returned to the outside facility approximately 4 days later with jaundice, weakness, fatigue and pain. A computed tomography (CT) scan of the abdomen and a nuclear cholescintigraphy scan confirmed a biliary leak with free intra-abdominal fluid consistent with biliary peritonitis (Fig. ). The patient was transferred to our critical care unit for further management.\nThe patient was placed on broad spectrum antibiotics and treated for atrial fibrillation with rapid ventricular response. Laboratory workup revealed a bilirubin level of 17 mg/dl, as well as profound protein–calorie malnutrition with an albumin of 1.9 gm/dl. A percutaneous cholangiogram was performed confirming a hilar ligation of his hepatic duct with inability to pass a wire or catheter distally. A right posterior and right anterior percutaneous cholangiogram catheter was placed for definitive biliary diversion (Fig. ). The patient was then managed with high calorie, high protein enteral nutrition through a nasogastric Dobhoff tube for approximately 7 days until able to tolerate appropriate oral intake for discharge. He was scheduled for follow-up in 2 weeks.\nAt follow-up, the patient had improved substantially. Repeat CT scan confirmed appropriate drainage of all abdominal fluid collections. His bilirubin improved to 1.2 mg/dl with an albumin of 3.1 gm/dl and prealbumin of 17.3 gm/dl. At this visit, he was scheduled for definitive biliary reconstruction approximately 2 months after his initial operation.\nDuring this operation, the porta was dissected and the common and proper hepatic arteries were identified and preserved. We were unable to palpate the previously placed percutaneous biliary catheters due to the high placement above the hilum at the level of multiple clips. We transected the CBD distally and removed numerous clips, finally noting bile drainage, but were unable to identify a cholangiogram catheter. We then identified a second tubular structure more lateral to the duct. We elected to transect this tissue, identifying a second extrahepatic bile duct. The anterior percutaneous catheter was identified proximally within the duct. An on-table cholangiogram with fluoroscopy was performed noting two separate extrahepatic biliary systems, draining the right and left lobes of the liver, respectively (Figs and ). Both distal ducts were ligated to definitively close the orifice to the duodenum and prevent spillage. A Roux limb of jejunum was created and anastomosed in a retrocolic fashion to the two separate hepatic ducts at the level of the hilum. A drain was placed, and there was no evidence of bile leakage.\nThe patient was discharged on postoperative Day 6 with normal hepatic function, normal bilirubin and no further complications. A follow-up cholangiogram at his postoperative clinic visit showed normal intrahepatic ducts with no evidence of stricture or leak, signifying successful repair of his injury with bypass of his duplicated biliary anatomy (Fig. ). His cholangiogram catheters were removed, and he was discharged from the clinic.
A 35-year-old female presented to a local hospital with a 3-month history of intermittent abdominal pain. Initial abdominal ultrasonography revealed cystic dilatation of the extrahepatic bile duct. A suspicion of choledochal cyst was made and was referred for surgical management. Her past medical history was unremarkable. She weighed 83 kg and was 164 cm tall, with body mass index of 30.9 kg/m2. Apart from mild right upper quadrant tenderness, her physical examination was unremarkable. Laboratory tests including liver and renal function tests, serum and urine amylase levels were normal. A magnetic resonance cholangio-pancreatography (MRCP) done showed a cystic fusiform dilatation of the common bile duct (CBD) extending into the right and left hepatic ducts (). No PBM was observed. The MRCP findings suggested type Ic CC. Without any further imaging, patient was scheduled for complete cyst excision with cholecystectomy and hepaticoenterostomy surgery. At laparotomy, the CBD was found to be fusiformly dilated. Bile samples were taken from the cyst and the gallbladder (GB) for amylase level essays. The GB was dissected from the liver bed and the cystic duct opened into the midportion of the cyst. After careful dissected of the cyst from surrounding vascular structures, the distal part entering the head of pancreas was noticed to be unaffected (). The distal part was transected just at the level of the head of pancreas and samples were taken for frozen section. Dissection at the hepatic hilum revealed two separate dilated ducts originating from the confluence of the left and right hepatic ducts and both entering into the cyst (). The two ducts were transected just distal to their origin from hepatic confluence to avoid confusing them as true right and left hepatic ducts (). The hepatic confluence was then opened to expose the true left and right hepatic ducts (). The dilated portions of the both hepatic ducts were transected and samples were taken for frozen section. A right and left hepaticojejunostomy reconstruction was done. No intraoperative cholangiogram was performed. Frozen section results of both the distal and proximal surgical margins were negative for malignancy. The amylase levels of both the cyst and GB were 47 031 and 44 770 U/L, respectively (normal serum amylase level: 25–110 U/L). Patient was discharged on postoperative Day 6. She is well with no evidence of malignancy after 23 months of follow-up.