Korean J Hepatobiliary Pancreat Surg.  2015 Feb;19(1):30-34. 10.14701/kjhbps.2015.19.1.30.

Customized left-sided hepatectomy and bile duct resection for perihilar cholangiocarcinoma in a patient with left-sided gallbladder and multiple combined anomalies

• Almodhaiberi H
• Hwang S
• Cho YJ
• Kwon Y
• Jung BH
• Kim MH

• KMID: 1802237
• DOI: http://doi.org/10.14701/kjhbps.2015.19.1.30

Abstract

Left-sided gallbladder (LSGB) is a rare anomaly, but it is often associated with multiple combined variations of the liver anatomy. We present the case of a patient with LSGB who underwent successful resection of perihilar cholangiocarcinoma. The patient was a 67-year-old male who presented with upper abdominal pain and obstructive jaundice. Initial imaging studies led to the diagnosis of Bismuth-Corlette type IIIB perihilar cholangiocarcinoma. Due to the unique location of the gallbladder and combined multiple hepatic anomalies, LSGB was highly suspected. During surgery after hilar dissection, we recognized that the tumor was located at the imaginary hilar bile duct bifurcation, but its actual location was corresponding to the biliary confluence of the left median and lateral sections. The extent of resection included extended left lateral sectionectomy, caudate lobe resection, and bile duct resection. Since some of the umbilical portion of the portal vein was invaded, it was resected and repaired with a portal vein branch patch. Due to anatomical variation of the biliary system, only one right-sided duct was reconstructed. The patient recovered uneventfully without any complication. LSGB should be recognized as a constellation of multiple hepatic anomalies, and therefore, thorough investigations are necessary to enable the performance of safe hepatic and biliary resections.

Keyword

Hepatectomy; Perihilar cholangiocarcinoma; Left-sided gallbladder; Anatomical variation

MeSH Terms

Abdominal Pain
Aged
Bile Ducts*
Biliary Tract
Cholangiocarcinoma*
Diagnosis
Gallbladder*
Hepatectomy*
Humans
Jaundice, Obstructive
Liver
Male
Portal Vein

Figure

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  Fig. 1 Magnetic resonance cholangiopancreatography images showing wide separation of the hilar bile ducts (A) without visualization of the usual B4 duct (B).

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  Fig. 2 Computed tomography image indicating the possible presence of the left-sided gallbladder (arrow).

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  Fig. 3 Computed tomography images showing the hepatic inflow vessels. Portal vein trifurcation is visible with complete occlusion of the left portal vein (A); A black arrow indicates the insertion site of the round ligament (B); The umbilical portion of the portal vein is partially invaded by the tumor (arrow, C); The hepatic arteries do not appear to have significant variation (D).

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  Fig. 4 Magnetic resonance cholangiopancreatography image superimposed by the pre-planned hepatic transection plane (dotted line).

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  Fig. 5 Computed tomography images taken at 10 days after surgery. Two middle hepatic vein trunks are visible (A); The portal vein branch to the theoretical left medial section is visible (arrow, B); The portal vein branch to the right anterior section is visible and an arrow indicates the site of branch patch repair (C); The portal vein branch to the right posterior section is visible (D).

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  Fig. 6 Gross photographs of the operative field after resection (A) and the resected specimen (B).

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