PMC9730159_01
Abdominal computed tomography (CT).. Abdominal axial CT shows a slightly speckled hyper-absorbed area in the gallbladder, and increased fatty tissue density around gallbladder.
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On abdominal computed tomography (CT), there was a speckled area of hyperdensity suggestive of multiple small stones in the gallbladder, as well as increased fatty tissue density around the gallbladder (Fig. 1).
Magnetic resonance cholangiopancreatography (MRCP) and drip infusion cholangiographic-computed tomography (DIC-CT).. MRCP shows the accessory hepatic duct (the posterior segment of the bile duct) (a) and DIC-CT reveals the cystic duct drains into accessory hepatic duct (b).
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The patient was diagnosed with acute cholelithiasis, and we conducted magnetic resonance cholangiopancreatography (MRCP), which revealed an anatomical anomaly within the biliary tract (Fig. 2a). Since we needed a more detailed understanding of the biliary tract, we used drip infusion cholangiographic-computed tomography (DIC-CT) (Fig. 2b).
Hisatsugu classification.. Type I, the cystic duct drains into the AHD. Type II, the cystic duct and the AHD drain into the common bile duct at the same level. Type III, the AHD drains into the common hepatic duct. Type IV, the AHD drains into the common bile duct at a site distal to the cystic duct confluence. Type V, the AHD drains into the cystic duct. AHD accessory hepatic duct, Gb gallbladder.
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Notably, the cystic duct drained into AHD; this is type 1 according to the Hisatsugu classification (Fig. 3).
Operative photographs.. Intraoperative photographs show the critical view of safety (a), and illuminated the accessory hepatic duct, cystic duct, and common hepatic duct by using the fluorescence cholangiography with indocyanine green (b). Also, the cystic artery and duct are safely dissected (c). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
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The neck of the gallbladder could be dissected almost smoothly, allowing us to expose the Calot triangle and achieve the critical view of safety (Fig. 4a). We could easily recognize the junction between the AHD and cystic duct, allowing us to safely and reliably dissect the cystic duct (Fig. 4b, c).