Clinical anatomy of the cystic duct

Variability of anatomy of the vesicular duct is an important aspect in surgical treatment of biliary tract. The classical variant is the fusion of the vesicular duct with the common hepatic duct at an acute angle in the middle third of the hepatic-duodenal ligament to form the common bile duct. However, there are also atypical anatomical variants, which can complicate diagnostics of biliary tract diseases and the operative treatment, especially during the laparoscopic cholecystic surgery. Understanding these variations is the key to reduce the risk of postoperative complications and improve the quality of medical care. Purpose of our work was to study the features of the clinical anatomy of the cystic duct.

Materials and methods. We analyzed domestic and foreign literature on this topic. This study included 350 medical histories of patients hospitalized in the surgical department of the State Autonomous Healthcare Institution "Central City Clinical Hospital No. 18 named after Professor K.Sh. Zyatdinov" in Kazan with the main clinical diagnosis: cholelithiasis, chronic calculous cholecystitis or acute calculous cholecystitis in the period from 2022 to 2024. Results and discussion. In the high variant of confluence, the fusion of the cystic duct with the common hepatic duct was found in 23 patients (88.5%), and the variant of confluence of the cystic duct with the right hepatic duct was found in 3 cases (11.5%). Among 62 cases of low confluence, 55 (89%) had confluence with the common hepatic duct from the lateral side, 5 patients (8%) had a parallel arrangement with the common hepatic duct, and 2 patients (3%) had a spiral course of the cystic duct with confluence with the common hepatic duct from the medial side.

Results and their discussion. The study revealed that in the high variant of the cystic duct entry in 23 patients (88.5% of cases), it merged with the common hepatic duct, and the variant of the cystic duct entering the right hepatic duct was observed in 3 cases (11.5%). Among 62 cases of low fusion, 55 (89%) had an entry into the common hepatic duct from the lateral side, 5 patients (8%) had a parallel location with the common hepatic duct, and 2 patients (3%) had a spiral course of the cystic duct entering the common hepatic duct from the medial side. These data emphasize the importance of taking into account abnormal anatomy to prevent intraoperative complications such as biliary tract injury.

Conclusion. Developmental anomalies of bile ducts in adults are not uncommon pathology, but they usually proceed without specific clinical manifestations. Accumulation of knowledge about the anomalous return of the cystic duct reduces the number of possible intraoperative complications

1. Timerbulatov M.V., Grishina E.E., Aitova L.R., Aziev M.M. Modern principles of safety in laparoscopic cholecystectomy. Zhurnal mien N.I. Pirogova = N.I. Pirogov Journal of Surgery. 2022;(12):104‑108. (In Russ.). https://doi.org/10.17116/hirurgia2022121104

2. Abasov S.Y., Aliev R.K., Romachenko P.N. Forecasting a «difficult» laparoscopic cholecystectomy. Izvestiya Rossiiskoi voenno-meditsinskoi akademii = Russian Military Medical Academy Reports. 2020; 39(1): 177-181. (In Russ.). https://doi.org/10.17816/rmmar43413

3. Romashchenko P.N., Maistrenko N.А., Pryadko A.S., Aliev A.K., Aliev R.K., Zherebtsov E.S. Prevention and treatment bile ducts injuries in patients with acute cholecystitis. Annaly khirurgicheskoy gepatologii = Annals of HPB surgery. 2020; 25 (3): 20–31. (In Russ.). https://doi.org/10.16931/1995-5464.2020320-31

4. Kurbanov D.M., Rasulov N.I., Ashurov A.S. Complications of laparoscopic cholecystectomy. Novosti Khirurgii = Surgery News. 2014; 22 (3): 366-373. (In Russ.). https://doi.org/10.18484/2305-0047.2014.3.366

5. Almasud R., Osmanova A.O., Mikhailichenko V.Y. Iatrogenic complications during laparoscopic cholecystectomy and their prevention. Nauchnoe obozrenie. Medicinskie nauki = Scientific review. Medical sciences. 2020;(4):7-11. (In Russ.). https://doi.org/10.17513/srms.1120

6. Sakhabetdinov B.A., Kurbangaleev A.I. Clinical anatomy of the cystic artery - variant anatomy. FORCIPE. 2023; (3): 72-73. (In Russ.).

7. Fujimoto N., Tomimaru Y., Yamamoto T., Hayashi Y., Noguchi K., Noura S. et al. Clinical investigation of the cystic duct variation based on the anatomy of the hepatic vasculature. Surg. Today. 2020; 50(4):396-401. https://doi.org/10.1007/s00595-019-01904-8

8. Al-Muhanna A.F., Lutfi A.M., Al-Abdulwahhab A.H., Al-Sharydah A.M., Al-Quorain A., Al-Muhanna A.F., Al-Dhaferi B.F. Magnetic resonance and retrograde endoscopic cholangiopancreatography-based identification of biliary tree variants: are there type-related variabilities among the Saudi population? Surg. Radiol. Anat. 2019;41(8):869-877. https://doi.org/10.1007/s00276-019-02249-0

9. Khalilov M.A., Sheverdin N.N., Moshkin A.S., Novikov M.S. The importance of variant anatomy of the cystic artery in surgery. Naukosfera. 2021; 11(1): 39–42. (In Russ.). https://doi.org/10.5281/zenodo.5665118

10. Uspensky Yu.P., Ivanov S.V., Vovk A.V., Koscheev A.V., Ganbarova Kh.I. Gallstone disease and metabolic syndrome: before and after the cholecystectomy. Lechaschi Vrach = The Practitioner. (In Russ.). 2019;(8):32. https://doi.org/10.26295/OS.2019.64.18.005

11. Bedin V. V., Korzheva I. Yu., Tavobilov M. M., Amirov M. Z. Difficulties in diagnosing choledocholithiasis with anomalies of the confluence of the cystic duct. Eksperimental'naya i klinicheskaya gastroenterologiya = Experimental and Clinical Gastroenterology. 2022;201(5): 158–160. (In Russ.). https://doi.org/10.31146/1682-8658-ecg- 201-5-158-160

12. Shilova A.N., Zharikova T.S., Koychuev K.R., Zharikov Yu.O., Nikolenko V.N. Variant anatomy of structures in Calot’s triangle. Tikhookeanskii meditsinskii zhurnal = Pacific Medical Journal. 2024;(1):24-28. (In Russ.). https://doi.org/10.34215/1609-1175-2024-1-24-28

13. Shadiev AM, Merkulova AG, Teterin YuS, Yartsev PA, Novikov SV. Intraoperative diagnosis of choledocholithiasis by endoscopic ultrasound. Dokazatel'naya gastroenterologiya = Russian Journal of Evidence-based Gastroenterology. 2024;13(1):6–11. (In Russ.). https://doi.org/10.17116/dokgastro2024130116

14. Ran X., Yin B., Ma B. Four Major Factors Contributing to Intrahepatic Stones. Gastroenterol. Res. Pract. 2017; (21): 1-5. https://doi.org/10.1155/2017/7213043.

15. Gupta V. How to achieve the critical view of safety for safe laparoscopic cholecystectomy: Technical aspects. Ann. Hepatobiliary Pancreat. Surg. 2023;27(2):201-210. https://doi.org/10.14701/ahbps.22-064

16. Pashko A.A., Bagaturiya G.O., Vasil'eva A.G., Mosyagin V.B., Rasteryaev A.N, Shurygina K.B. The importance of topographic and anatomical landmarks in modern laparoscopic operation. FORCIPE. 2022; 5(4):4-8. (In Russ.).

17. Taghavi A., Azizi M., Rasekhi A., Gholami Z. Anatomic Variations of the Cystic Duct in Magnetic Resonance Cholangiopancreatography in Shiraz: A Cross-Sectional Study. Iran. J. Med. Sci. 2022;47(1):48-52. https://doi.org/10.30476/IJMS.2021.88447.1918

18. Tarasenko S.V., Natalsky A.A., Peskov O.D., Tarakanov P.V. Clinical case of rare extrahepatic bile duct anomaly. Nauka molodykh = Science of the young. 2019;7(3):408-414. (In Russ.). https://doi.org/10.23888/HMJ201973408-414

19. Nichipor E. A., Serova N. S. Radiology of gallbladder and extrahepatic bile ducts diseases. Rossiiskii elektronnyi zhurnal luchevoi diagnostiki = Russian Electronic Journal of Radiology. 2016; 6 (2):80-90. https://doi.org/10.21569/2222-7415-2016-6-2-80-90.

20. Rothman J.P., Burcharth J., Pommergaard H.C., Viereck S., Rosenberg J. Preoperative Risk Factors for Conversion of Laparoscopic Cholecystectomy to Open Surgery - A Systematic Review and Meta-Analysis of Observational Studies. Dig. Surg. 2016;33(5):414-23. https://doi.org/10.1159/000445505.