Management of rare biliary duct variants using a nasobiliary drainage tube and wire-guided navigation during laparoscopic cholecystectomy: a case report

Biliary anatomical variation is an important risk factor for bile duct injury during laparoscopic cholecystectomy [1]. In the present case, we used a nasobiliary drainage tube and wire-guided navigation to identify a rare biliary variant and provide intraoperative guidance to reduce the risk of bile duct injury during laparoscopic cholecystectomy ([Video 1]).

Video 1 Use of a nasobiliary drainage tube and wire-guided navigation to identify a rare biliary variant and provide intraoperative guidance to reduce the risk of bile duct injury during laparoscopic cholecystectomy.

A 29-year-old woman was admitted with a 3-day history of upper abdominal pain and jaundice. Magnetic resonance cholangiopancreatography revealed that the cystic duct inserted into the right posterior sectoral duct (RPSD) and a suspected stone was located at the lower end of the common bile duct ([Fig. 1]). Endoscopic retrograde cholangiopancreatography confirmed the presence of an abnormal junction between the cystic duct and RPSD ([Fig. 2 a]), classified as type 4A according to the right hepatic duct variant classification by Huang et al. [2]. Attempts to selectively cannulate the RPSD using a sphincterotome and guidewire were unsuccessful. However, we successfully cannulated the RPSD using a nasobiliary drainage tube (nasal biliary drainage catheter, ENBD-7-LIGUORY-C; Cook, Limerick, Ireland) and wire-guided navigation, confirming the aberrant junction of the cystic duct with the RPSD ([Fig. 2 b]). During surgery, the surgeon injected indocyanine green through the nasobiliary catheter to identify the RPSD and avoid its injury ([Fig. 3]). Postoperative nasobiliary tube cholangiography revealed unobstructed flow in the RPSD ([Fig. 4]).

Fig. 1 Magnetic resonance cholangiopancreatography (MRCP) showing that the cystic duct inserted into the right posterior sectoral duct and that a suspected stone was located at the lower end of the common bile duct.

Fig. 2 Endoscopic retrograde cholangiopancreatography showing: a a rare biliary anatomical variant; and b successful cannulation of the right posterior sectoral duct using a nasobiliary drainage tube and wire-guided navigation.

Fig. 3 Injection of indocyanine green through the nasobiliary drainage tube to identify the right posterior sectoral duct and avoid injury to it.

Fig. 4 Postoperative nasobiliary tube cholangiography showing unobstructed flow in the right posterior sectoral duct.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Keplinger KM, Bloomston M. Anatomy and embryology of the biliary tract. Surg Clin North Am 2014; 94: 203-217
• 2 Huang TL, Cheng YF, Chen CL. et al. Variants of the bile ducts: clinical application in the potential donor of living-related hepatic transplantation. Transplant Proc 1996; 28: 1669-1670

Publication History

Article published online:
15 June 2023