Double Cystic Duct in a Patient with Sinus Inversus Totalis

Abstract

Purpose: Double cystic duct is a rare congenital anomaly. Here we describe a patient with situs inversus and biliary pancreatitis who had a double cystic duct complicating laparoscopic cholecystectomy. A 49-year-old male with sinus inversus totalis was referred to our institution for an ERCP. The patient had a history of multiple episodes of left upper quadrant pain. Following the resolution of the first episode, he underwent open cholecystectomy in which a double cystic duct was found. An IOC showed a delayed passage of contrast into the duodenum, raising suspicion of choledocholithiasis. He was referred to our institution for endotherapy. A tube cholangiogram delineated the opacified the cystic duct bearing the biliary tube drain that joined the common bile duct (CBD) (Figure 1). An ERCP was performed under general anesthesia with the patient in the conventional left lateral semiprone position. Attempted cannulation was extremely difficult and biliary access was possible only after a needle-knife sphincterotomy. Retrograde cholangiography confirmed a CBD stone, but could not be retrieved. A 10F biliary stent was deployed ensuring free flow of bile. He was observed overnight and discharged the following morning without any complications. Variations in cystic duct anatomy are common. However, very few cases of a double cystic duct draining into a single gallbladder have been reported. When any of these variations are suspected, a cholangiography or ERCP is recommended to define the anatomy, and then a cholecystectomy can be completed safely. If the anatomy is not defined, there is a high chance of surgical complications from injury to the bile duct system. Complicating the clinical picture was the sinus inversus totalis anomaly of his biliary tract. The most challenging aspect of performing an ERCP is the mirror image anatomy. In a patient with sinus inversus, many people have recommended performing a right-sided approach, in conjunction with the anomalous anatomy. In summary, a double cystic duct is a rare congenital anomaly that becomes further complicated when the patient has sinus inversus and develops choledocholithiasis. An intraoperative cholangiogram could help defining the anatomy and help to minimize the risk of complications.Figure