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J Gandhara Med Dent Sci
January - March 2025
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ORIGINAL ARTICLE
How to cite this article
Khan MB, Iftikhar M, Ahmad S.
Anatomical Variations of Extrahepatic
Biliary Tract and Related Vessels
during Laparoscopic Cholecystectomy.
J Gandhara Med Dent Sci. 2025; 12(1):
3-6.doi:10.37762/jgmds.12-1.623
Date Submission: 10-09-2024
Date Revised: 06-11-2024
Date Acceptance: 19-11-2024
1Specialist Registrar, Hayatabad
Medical Complex Peshawar
3Professor Department of Surgical “C”
Unit, Hayatabad Medical Complex
Peshawar
Correspondence
2Muhammad Iftikhar, Associate
Professor, Department of General
Surgery, Hayatabad Medical Complex
Peshawar
+92-333-9177399
if_khattak@hotmail.com
ANATOMICAL VARIATIONS OF EXTRAHEPATIC BILIARY TRACT AND RELATED
VESSELS DURING LAPAROSCOPIC CHOLECYSTECTOMY
Muhammad Bilawal Khan1, Muhammad Iftikhar2, Siddique Ahmad3
ABSTRACT
OBJECTIVES
This study aims to add to the existing knowledge by evaluating the frequency
of usual pathologies in the biliary system and blood vessels observed during
Laparoscopic cholecystectomy.
METHODOLOGY
This cross-sectional study was conducted at the General Surgery Department
of Hayatabad Medical Complex, Peshawar, from November 2022 to
November 2023. The study comprised 65 patients aged 18-50 with known
cases of cholelithiasis. Exclusion criteria included patients with empyema
gallbladder, gallbladder carcinoma, and a history of diabetes mellitus or
hypertension.
RESULTS
The mean age of patients was 40.1±3.95 years, with females comprising
64.6% and males comprising 35.4% of the sample. Overall, extrahepatic
biliary tract anomalies were found in 24.6% of cases. The incidence of
anatomic variations in the present study was as follows; a short cystic duct
was the most frequent variation observed in the present study and was found
in 9.2%, followed by a long cystic duct (7.7%), duct of Luschka, and
Moynihan hump anomaly (3.1% each).
CONCLUSION
Out of all the parameters, short cystic duct predominated, emphasizing the
signicance of a perfect surgical approach. The fact that anomalies are
distributed equally across the various demographics underlines their inherent
attributes. These ndings call for further research that will enhance the
performance of surgeries and the benets of laparoscopic cholecystectomy
treatments.
KEYWORDS: Laparoscopic Cholecystectomy, Anatomical Variations,
Biliary Tract Anomalies, Surgical Outcomes, Gallstone Disease
INTRODUCTION
Gallstone disease is still a signicant health problem
worldwide, as more than one-third of the adult
population has gallstones. Since its introduction,
laparoscopic cholecystectomy (LC) has become the
gold-standard treatment for symptomatic gallstone
diseases.1 It has shown rapid worldwide acceptance
because it is minimally invasive, with a success rate of
over 95 % in treating benign conditions. Nevertheless,
the outcome of this surgical measure is highly
dependent on knowledge about anatomical variations
and potential anomalies likely to be encountered during
surgery.3 The extrahepatic biliary tract has a complex
anatomy known to be variable, and variations are
described in the literature.4 These variations are
anatomic anomalies like long cystic duct, short cystic
duct, bile leakage due to the accessory duct (Luschka),
and vascular anomalies like aberrant cystic artery.
Surgeons must recognize and understand these
anomalies to maneuver through the biliary system.5
Short cystic ducts are known to be associated with a
high grade of diculty during cholecystectomy
procedure, making meticulous dissection crucial in
avoiding iatrogenic injury.6 On the contrary, long cystic
ducts are less commonly observed, so customized
surgical approaches should be taken to accommodate
that issue and better clinical outcomes.7 In addition, the
presence of ducts of Luschka and a Moynihan hump (a
peculiar “humped” cystic duct) poses surgical
challenges.8,9,10 In addition, the accessory cystic artery
should be carefully preserved to avoid iatrogenic
injuries while dissecting Calot’s triangle.10 While
existing literature has explored these anomalies
individually, there is a paucity of comprehensive
studies investigating their collective frequency within a
specific patient population. Through meticulously
analyzing demographic data and stratied
examinations, our study seeks to elucidate potential
associations between these anomalies and age, gender,
4J Gandhara Med Dent Sci January - March 2025
and other relevant factors. Furthermore, this research
endeavors to enhance understanding of common
extrahepatic biliary tract and vascular anomalies,
rening surgical techniques and optimizing patient
outcomes in laparoscopic cholecystectomy.
METHODOLOGY
This Cross-sectional study was carried out at the
General Surgery Department, Hayatabad Medical
Complex Peshawar, from November 2022 till
November 2023. A total of 65 patients were included in
the study. Patients of both genders, ages 18-50 years,
and diagnosed cases of cholelithiasis on ultrasound
were included in the study. Patients with empyema
gallbladder, carcinoma gallbladder, history of diabetes
mellitus, and hypertension were excluded from the
study. The purpose and benets of the study were
explained to patients, and proper written informed
consent was obtained. All patients who met inclusion
criteria were assessed in detail by taking adequate
history, conducting a clinical examination, and
conducting a routine investigation. History was taken
regarding age, gender, diabetes mellitus, and
hypertension. Height and weight were measured, and
BMI was calculated. In Laparoscopic cholecystectomy,
attention was given to anomalies. Under general
anesthesia, all the surgeries were performed by the
same surgeon and using the same technique of critical
view of safety for laparoscopic cholecystectomy. Data
was collected using structured proforma. All the data
analysis was done in Statistical Package for Social
Sciences (SPSS) version 25.0. Frequency and
percentages were calculated for gender, extrahepatic
biliary tract, and vascular anomalies. Mean + Standard
deviation was computed for numerical variables like
age, height, weight, and BMI. Anomalies were
stratied in age and gender distribution. Post-
stratication, a chi-square test was used. A p-value of
less than 0.05 was considered as signicant. All the
research was presented in the form of tables and charts.
RESULTS
The mean age of patients was 40.1±3.95 years. Females
comprised 64.6% of the study sample. The mean BMI
was 31.5±3.76 kg/m2. Overall, 16 patients (24.6%) had
anatomical anomalies of the extrahepatic biliary tract
and related vessels.
Table 1: Enlisting Characteristics of Patients with Placenta
Previa
Demographics Mean ± SD
Age (years) 40.107±3.95
Weight (Kg) 82.153±5.34
Height (m) 1.620±0.07
BMI (Kg/m2) 31.528±3.76
Abnormal anatomy of the extrahepatic biliary tract was
found to be 16(24.6%), amongst which the most
common one was short cystic duct 6 (9.2%), followed
by long cystic duct 5 (7.7%), duct of Luschka and
Moynihan hump anomaly 2 (3.1%) cases each and
accessory cystic artery was the least common anomaly,
seen in only 1 (1.5%) patient respectively.
Anatomical Variations of Extrahepatic Biliary Tract and Related
Table 2: Frequency of Dierent Anomalies
Anomaly Frequency %age
Short cystic duct 06 9.2
Long cystic duct 05 7.7
Luschka 02 3.1
Moynihan hump 02 3.1
Accessory cystic artery
01 1.5
Stratification of anomalies by age and gender showed
no statistically signicant association.
Table 3: Stratication of Anomalies to Gender
Gender
Long
Cystic
duct
Short
Cystic
duct
Duct of
Luschka
Moynih
anhump
Accessory
Cystic
artery
Male 02(8.7%)
04(17.4%)
0(0%) 0(0%) 0(0%)
Female
03(7.1%)
02(4.8%)
02(4.8%)
02(4.8%)
01(2.4%)
P-Values 0.822 0.093 0.288 0.288 0.456
Table 4: Stratication of Anomalies to Age (Years)
Age
(years)
Long
Cystic
duct
Short
cystic
duct
Duct of
Luschka
Moynihan
hump
Accessory
cystic
artery
18-35 0(0%) 1(10%)
0(0%) 1(10%) 0(0%)
36-50 5(9.1%)
5(9.1%)
2(3.6%) 1(1.8%) 1(1.8%)
P-Values
0.321 0.927 0.540 0.168 0.667
Figure 1: Stratication of Anomalies for Gender and Age Groups
DISCUSSION
The present study delves into the frequency of common
extrahepatic biliary tract and vascular anomalies in
patients undergoing laparoscopic cholecystectomy,
shedding light on the prevalence and characteristics of
anatomical variations.11 These ndings hold
significance in surgical planning, intraoperative
decision-making, and postoperative outcomes. The
demographic prole of our study cohort revealed a
mean age of 40.1±3.95 years, with a predominant
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J Gandhara Med Dent Sci
January - March 2025
female representation of 64.6%. This is not surprising
in that gallstone disease has a long-recognized
association with the female gender, and hormonal
issues are known to impact the higher prevalence of
gallstones among women.12 We also nd a positive
relation between obesity and gallstone formation with a
mean BMI of 31.5±3.76 kg/m2. This was consistent
with published literature.13,14 Extrahepatic bile ducts
and blood vessel anomalies were found in 24.6% of the
patients within our series, ranging from “normal
appearance” to very complex structural malformations.
The most common anomaly noted in 9.2% was the
presence of a short cystic duct, followed by long CD
(7.7%), Moynihan hump, and Duct of Luschka
anomalies were observed at a frequency rate of 3%
each. Accessory cystic artery was the anomaly that was
observed to be the most uncommon (1.5 % of patients).
It stresses that all the surgeons doing laparoscopic
cholecystectomy must be vigilant about their existence
as they can pose a challenge for Lap Cholecystectomy.
The absence of statistical signicance for age or gender
in the present study may indicate that these variants are
distributed uniformly across demographics. This
supports the multifactorial origin of gallstone disease
and suggests that the spectrum of anatomic abnormality
is too heterogeneous to show any age or gender
specificity. The incidence of the short cystic duct
(9.2%) is consistent with reported rates ranging
between 6 and 11% in other studies.15 The long cystic
duct was identied with a frequency of 7.7%, consistent
with previously reported, proving the increased
compilation data on this infrequent anomaly.16 Finally,
a rare anomaly, i-e, accessory cystic artery (1.5%), this
study reinforces the need for careful and meticulous
dissection in exploring Calot‟s triangle.17 A
stratication by age and gender revealed that this is
probably the only way of distribution, as no statistically
signicant associations could be demonstrated. This
finding is consistent with current literature, which
suggests that structural variants of the pyramids in
patients are constitutive rather than dependent on age or
sex. The results of our study add to the literature about
age, sex, and biliary anomalies.18 In line with our
findings, multiple authors, in their studies of biliary
variations, did not nd any age or gender predilections.
This uniformity in the discrepancies of dierent
anatomical features across various demographics
confirms that these dierences are ingrained in all
humans.
LIMITATIONS
Although our study provides valuable insights,
limitations still need to be addressed. Our study has
limitations: a) our investigation was performed at only
one center, and b) the "n" of 65 is a small sample size
and could limit our statistical power to estimate ecacy
accurately. A more extensive and multicenter study
may enhance the external validity of our results.
Consequently, although we did not report on the
surgical implications of these ndings in our research
precisely because it was outside its scope (mainly
looking at characteristic frequencies), this limitation
may need to be addressed. The clinical impact of these
anatomical nuances can now be explored in a further
study, such as laparoscopic cholecystectomy.
CONCLUSIONS
The present observational cohort study highlights the
incidence and features of various common anomalies
affecting the extrahepatic biliary tract during
laparoscopic cholecystectomy. The most common
anomaly was a short cystic duct, which underlines the
importance of good surgical anatomy. The fact that
these anomalies live amongst various demographic
groups paints the picture egregiously. Despite being
essential and informative, these ndings support a more
significant research trajectory toward implementing
specific surgical techniques to improve outcomes in
laparoscopic cholecystectomy procedures.
CONFLICT OF INTEREST: None
FUNDING SOURCES: None
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CONTRIBUTORS
1. Muhammad Bilawal Khan - Concept & Design; Drafting
Manuscript
2. Muhammad Iftikhar - Data Analysis/Interpretation; Critical
Revision
3. Siddique Ahmad - Concept & Design; Critical Revision
Anatomical Variations of Extrahepatic Biliary Tract and Related
