Biliary anatomy

1. The cystic duct and Callot triange:
important educational reminder
A case series: personal practice analysis
R. Lunevicius, MD, PhD, FRCS (Engl.)
Consultant General Surgeon
MM and Audit meeting, Aintree, Liverpool, 2018

2. Cystic duct
anatomical variant – lateral insertion into CHD >50%
2

3. Cystic duct (No. 26)
Parallel course to CHD: long CD / calculi: 28/9 /12
3

4. Cystic duct
spiral course of anteroductal or retroductal CD with medial insertion into CHD
4

6. One hospital spell due to AC
Length of stay: 1 day
Indication for ERCP: calculus / CBD
Complication of ERCP:
Injury to the extrahepatic BD
Puncture perforation of BD by wire
Variant of anatomy of BDs:
Fusion of RPD and CHD
No Right Hepatic Duct
B7
B6
RPD CHD
LHD
B8
B5
B4
LLD
B3
B2
stent

7. 12 weeks later: removal of stent, re-ERCP
RPD in between CD and CHD (within area of Callot):
RPD drains 30% of bile from the liver
No Right Hepatic Duct
CD
RPD
LHDRAD
CHD
CBD

8. Operation in 2 weeks’ time:
Laparoscopic subtotal cholecystectomy, drainage
• Chronic inflammatory mass covering G-B & hepatoduodenal lig.
• Omentum detached from Gf and Gb
• Aspiration (no bile, dense mucocele/pus)
• Solid mass at the level of Hartmann’s pouch & hepatoduodenal lig.
• Removal of peritoneal wall of Gb and Gf
• Removal of 12 moderate size pigmental gallstones
• Removal of mucosa of hepatic wall of Gb and Gf & drainage (1)

9. Important educational reminder
• Check all images: a must thing before cholecystectomy
– Firstly: confirm presence of the gallbladder
– Secondly: analyse anatomy of the biliary tract
– Thirdly: plan biliary surgery
• The case: a risk of misidentification (ex: one or two CAs) of the
important structures within or around the area of Callot if surgical
pathology of the gallbladder would have been favourable for total
cholecystectomy

10. Triad of surgery
1. ANATOMY
2. PATHOLOGY
3. SURGEONS