CASE 2 A 74-year-old man with a history of prostatism, right inguinal herniorrhaphy, and traumatic subdural hema- toma was referred to our department for repeated biliary colic and recurrence of a right inguinal hernia. Laparo- scopic cholecystectomy and right inguinal hernioplasty were performed. The immediate postoperative period was unfavorable: the patient was apyretic but presented with nausea, vomiting, and diffuse abdominal discomfort of low intensity. On the fourth postoperative day, an ultra- sound scan showed free intraabdominal liquid. Emer- gency laparotomy revealed generalized choleperitoneum due to biliary leakage from a duct of Luschka, which was sutured. Intraoperative cholangiography confirmed that the main bile duct was intact. The second postoperative period was satisfactory, and he was discharged from the hospital 5 days after the second surgery. DISCUSSION The duct of Luschka, first described in 1863, is an acces- sory bile duct originating in the right hepatic lobe, which is located very close to the gallbladder bed and drains into the right or common hepatic duct.2 Duct of Luschka injury can cause a choleperitoneum, biloma, or subphrenic or subhepatic intraabdominal abscess.5 The true frequency of the duct of Luschka in the population is unknown and ranges from 1% to 50% according to published series.2 Injury during LC is usually produced by an excessively deep plane of dissection and by the particular anatomical localization of this accessory duct. In the classification of iatrogenic injuries of the biliary tree by Strasberg et al,6 wider than the classification by Bis- muth, duct of Luschka injury is included in type A. The real incidence is difficult to estimate. A systematic review by Strasberg et al6 reported 270 iatrogenic injuries of the biliary tree and classified 62 as type A, of which 15% (12 cases) were duct of Luschka leaks, 4.4% of all of the iatrogenic bile duct injuries and 0.047% of the LCs per- formed.6 A review by Deziel1 described 48 injuries to aberrant bile ducts (10.4% of total bile duct injuries and 0.06% of LCs studied). The incidence in our series was 0.15%. A Strasberg type-A bile duct injury is not usually identified during an LC and clinically manifests in the first postop- erative week. Three clinical patterns of presentation exist: abdominal pain with fever and symptoms of local or general sepsis, or both, external bile fistula, and mild nonspecific symptoms. Very elevated bilirubin levels are uncommon in these patients. Among type A injuries, la- tent clinical symptoms are more common in the duct of Luschka than in cystic duct leakage,2 as in the present cases. Numerous diagnostic methods have been used to detect these injuries, including abdominal ultrasound and com- puted tomography, endoscopic retrograde cholangiopan- creatography, percutaneous transhepatic cholangiogra- phy, and hepatic iminodiacetic acid scan.1,6 Nevertheless, careful clinical examination is still of utmost importance. In our first case, a correct diagnosis was delayed by our assumption that the scant abdominal liquid derived from fenestrated cysts. Treatment with sphincterotomy, endoscopic insertion of a biliary stent, and percutaneous drainage of the biloma is usually effective in a large percentage of patients.2,6 In patients who present with acute abdomen, as in our cases, or who are not cured by noninvasive treatments, explor- atory laparotomy is the best approach and is carried out in 30%6 to 56% of cases.1 The surgical treatment consists of a lavage of the abdominal cavity, closure of the duct of Luschka,6 and intraoperative cholangiography to that con- firm the biliary tree is intact. References: 1. Deziel DJ, Millikan DW, Economou SG, Doolas A, Ko ST. Complications of laparoscopic cholecystectomy: a national sur- vey of 4292 hospitals and analysis of 77604 cases. Am J Surg. 1993;165:9 –14. 2. Frakes JT, Bradley SJ. Endoscopic stent placement for biliary leak from an accessory duct of Luchska after laparoscopic cho- lecystectomy. Gastrointest Endosc. 1993;39:90 –92. 3. Russell JC, Walsh SJ, Mattie A, Lynch JT. Bile duct injuries 1989 –1993. Arch Surg. 1996;131:382–388. 4. Richardson MC, Bell G, Fullarton GM. Incidence and nature of bile duct injuries following laparoscopic cholecystectomy. Br J Surg. 1996;83:1356 –1360. 5. McQuillan T, Manolas SG, Hayman JA, Kune GA. Surgical significance of the bile duct of Luchska. Br J Surg. 1989;76:696 – 698. 6. Strasberg SM, Hetl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopy cholecystectomy. J Am Coll Surg. 1995;180:101–125. JSLS (2005)9:216 –217 217