[Cysto-hepatic ducts; surgical consequences. Apropos of 29 cases]

Cysto-hepatic ducts are a rare entity constituting less than 2% of biliary tract operations. Twenty-nine cases have been encountered in our General Surgical Service between 1980 and 1989. The frequency is about 2.3% in a series of 1,265 operative and/or postoperative cholangiographies analysed during the same period. Cystohepatic ducts were discovered in 3 cases at dissection, in 10 cases on operative cholangiography, in one case after biliary tract lesion, and in 15 cases on postoperative cholangiography. The cystohepatic duct was voluntarily or involuntarily respected in 23 cases, voluntarily ligated in one case, involuntarily in 2 others, cut and drained outside in one case, injured and repaired in one case, and cut in another. From our experience, we conclude that the roles of dissection of the cystic duct and the recognition of well known biliary bifurcation do not permit in all cases to avoid common bile duct lesions, particularly in the presence of an unforeseeable and dangerous variant such as a cystohepatic duct draining a large hepatic territory. As a result, the first stage of cholecystectomy should not be dissection of the biliary bifurcation, ligation of the cystic duct and its intubation but especially dissection of all elements of Budd's triangle before intubation of the supposed cystic duct. This avoids leaving upstream from the sectioned cystic duct, an hepatic territory not drained by the common bile duct. A good quality systematic operative cholangiography reveals in the other cases this anatomical variant and constitutes an essential medico-legal document for the patient's and surgeon's safety.