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Kim, Kim, Kim, Suh, Shin, Kim, Park, and Lim: The Variation of Hepatic Duct Confluence and Asymptomatic Common Bile Duct Stone with Routine Intraoperative Cholangiogram during Laparoscopic Cholecystectomy
Original Article

Korean J Gastroenterol 2011;58(6):338-345.

Published online: 4 October 2011

DOI: https://doi.org/10.4166/kjg.2011.58.6.338

The Variation of Hepatic Duct Confluence and Asymptomatic Common Bile Duct Stone with Routine Intraoperative Cholangiogram during Laparoscopic Cholecystectomy

Se Young Kim, Ki Ho Kim, Il Dong Kim, Byung Sun Suh, Dong Woo Shin, Sang Wook Kim, Jin Soo Park, Hye In Lim

Department of Sugery, Bundang Jaesaeng Hospital, Seongnam, Korea

Correspondence to: Se Young Kim, Department of Sugery, Bundang Jaesaeng Hospital, 255-2, Serhyeon-dong, Bundang-gu, Seongnam 463-050, Korea. Tel: +82-31-779-0170, Fax: +82-31-779-0467, E-mail: cutefrog76@naver.com

Received 20 July 2011       Accepted 24 October 2011

Copyright © 2011 Korean Ophthalmological Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

Intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy (LC) has been used to evaluate bile duct stone. But, the routine use of IOC remains controversial. With routine IOC during LC, we reviewed the variation of hepatic duct confluence and try to suggest the diagnostic criteria of asymptomatic common bile duct (CBD) stone.

Methods

We reviewed the medical record of 970 consecutive patients who underwent LC with IOC from January 1999 to December 2009, retrospectively.

Results

Nine hundered seventy patients were enrolled. IOC were successful in 957 (98.7%) and unsuccessful in 13 (1.3%). Eighty two of 957 patients (8.2%) were excluded because of no or poor radiologic image. According to Couinaud's classification, 492 patients (56.2%) had type A hepatic duct confluence, 227 patients (26.1%) type B, 15 patients (17%) type C1, 43 patients (4.9%) type C2, 72 patients (8.2%) type D1, 21 patients (2.4%) type D2, 1 patient (0.1%) type E1, 1 patient (0.1%) type E2, 2 patients (0.2%) type F, and 1 patient (0.1%) no classified type. The CBD stone was found in 116 of 970 (12.2%) patients. In 281 patients, preoperative serologic and radiologic tests did not show abnormality. When preoperative findings were not remarkable, there was no difference of clinical features between patients with or without CBD stones.

Conclusions

Although IOC during LC has some demerits, it is a safe and accurate method for the detection of CBD stone and the anatomic variation of intrahepatic duct.

Keywords: Intraoperative cholangiogram, Laparoscopic cholecystectomy, Intrahepatic bile ducts, Asymptomatic bile duct stone

References

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Fig. 1.
IOC flow chart. It shows the process of IOC and how to confirm CBD stone defected with IOC. IOC, intraoperative cholangiogram; CBD, common bile duct; LC, laparoscopic cholecystectomy.
kjg-58-338f1.tif
Fig. 2.
It is unclassified hepatic duct confluence type.
kjg-58-338f2.tif
Table 1.
Reasons for Not Doing Intraoperative Cholangiogram
  N (%)
Normal preoperative ERCP 25 (25)
No radiologist 13 (13)
Short cystic duct 4 (4)
GB polyp 28 (28)
Poor anatomy 7 (7)
Unstable patient 2 (2)
Prior biliary drainage inserted 1 (1)
Bleeding 1 (1)
Adhesion 2 (2)
Proven malignancy in frozen section 1 (1)
Others 15 (15)
Total 99 (100)

GB, gallbladder.

Table 2.
Reasons for Conversion to Open Cholecystectomy
  N (%)
Adhesion 41 (86)
Failed cystic duct ligation 2 (4)
Cystic duct injury 1 (2)
Failed choledochoscopic removal of CBD stone 1 (2)
CBD injury 2 (4)
Malignancy 1 (2)
Total 48 (100)

CBD, common bile duct.

Table 3.
Cross Data between IHD Type and Cystic Duct Confluence Position
    Cystic duct confluence position, n (%)
CBD RHD RPHD RAHD LHD Total
IHD A 483 (55.2) 8 (0.9) 0 0 1 (0.1) 492 (56.2)
  B 223 (25.5) 4 (0.6) 0 0 0 227 (26.1)
  C1 12 (1.4) 0 1 (0.1) 2 (0.2) 0 15 (1.7)
  C2 42 (4.8) 0 1 (0.1) 0 0 43 (4.9)
  D1 72 (8.2) 0 0 0 0 72 (8.2)
  D2 21 (2.4) 0 0 0 0 21 (2.4)
  E1 1 (0.1) 0 0 0 0 1 (0.1)
  E2 1 (0.1) 0 0 0 0 1 (0.1)
  F 2 (0.2) 0 0 0 0 2 (0.2)
  No classified 1 (0.1) 0 0 0 0 1 (0.1)
  Total 858 (98.0) 12 (1.5) 2 (0.2) 2 (0.2) 1 (0.1) 875 (100)

IHD, intrahepatic duct; CBD, common bile duct; RHD, right hepatic duct; RPHD, right posterior hepatic duct; RAHD, right anterior hepatic duct; LHD, left hepatic duct.

Table 4.
Anatomincal Variation in Intraoperative Cholangiogram
  n (%)
Pancreatic opacification 117
Anomaly of pancreaticobiliary duct union 12
Choledochal cyst 2
Others 6
Total 137
Table 5.
Results of Intraoperative Cholangiogram
  n (%)
True positive 96 (9.9)
True negative 852 (87.8)
False positive 20 (2.1)
False negative 2 (0.2)
Total 970 (100)
Table 6.
Comparative Analysis of Asymptomatic Common Bile Duct Stone
  Group 1 (n=12) Group 2 (n=269) p-value
Age (mean, yr) 54.6 50.62 .478 a
BMI (mean) 24 24.5 .670 a
ASA (I： II： III, %) 58：25：17 77：21：2 .730 b
Gender (male： female, %) 42：58 40：60 .417 b
Period from test to IOC (mean, day) 1.75 1.98 .912 a
GB stone number (mean) 5.38 4.41 .467 a
GB stone size (mean, mm) 10.13 9.07 .752 a
GB wall thickness (mean, mm) 4.0 3.56 .568 a

ASA, American Society of Anesthesiologist; IOC, intraoperative cholangiogram; GB, gallbladder.

a Student t-test

b χ2 test.

Table 7.
Data of Asymptomatic Common Bile Duct Stone
Case No. Asymptomatic common bile duct stone case
1 2 3 4 5 6 7 8 9 10 11 12
Number 1 1 2 3 5 6 6 6 7 ≥10 ≥10 ≥10
Size (mm) 10 25 3–10 2–5 2–3 3–10 3–10 3–10 2–5 ≤2 2–4 1–10
Component PC PC PC PC CB PC BP CB CB CB MC CB

CB, calcium bilirubinate stone; PC, pure cholesterol stone; BP, black pigmented stone; MC, mixed cholesterol stone.

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