SUBVESICULAR BILE DUCT LEAK AFTER CHOLECYSTECTOMY OF A SINISTROPOSITIONED GALLBLADDER

Objectives: Case Description
A 38-year-old female with history of laparoscopic roux-en-y bypass and caesarian section was originally seen for evaluation of persistent mid abdominal pain with radiation to the left upper quadrant. She had mild tenderness in the mid abdominal area. Labs including complete blood count, hepatic panel, amylase and lipase were normal however abdominal ultrasound revealed cholelithiasis with a mildly hydropic gallbladder, trace pericholecystic fluid and a common bile duct diameter of 7 mm. The patient was consented and underwent outpatient robotic-assisted cholecystectomy with cholangiogram two days after being seen in clinic.
Intraoperatively, three robotic trocar ports and a single assistant port were placed per the surgeon's standard robotic-assisted technique. The gallbladder appeared to be located on the left lobe of the liver. There was inadequate retraction of the gallbladder in that left-sided position and clearing of the cystic plate was difficult due to visualization, so a top down dissection was done. The cystic duct was eventually identified and isolated. Due to the patient’s roux-en-y anatomy and seven millimeter duct, a cholangiogram was performed which revealed no evidence of leak or filling defect.
The patient returned to the emergency room on post-operative day three with worsening right upper pain that was different from her pre-operative pain. Labs showed a slight leukocytosis and total bilirubin of 1.6. CT scan revealed fluid in the right upper quadrant and subsequent hepatobiliary scan showed concern for persistent bile leak. The patient was taken back to the operating room for diagnostic laparoscopy where the cystic duct clips appeared intact but a bile leak was discovered in the dissection bed at the superior aspect of the liver bed. The source appeared to from a subvesicular duct. This leak was closed with absorbable suture in a figure of eight fashion. A drain was placed in the dissection bed. The patient was discharged on post-operative day two with the drain in place. The drain remained serosanguinous and was removed in clinic follow-up.

Discussion
A sinistropositioned gallbladder is rare and most frequently discovered intraoperatively. A high degree of suspicion for other anatomic abnormalities including portal vein, cystic artery, and biliary tract variations should proceed. Particularly, biliary tract variants not limited to subvesicular ducts (ducts of Luschka) can be a source of morbidity. Additional adjuncts including altered port position, dome down dissection, cholangiography, and fluorescence imaging should be considered when a sinistropositioned gallbladder is encountered.

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