A CASE OF INTRAOPERATIVE DISCOVERY OF ABERENT SUBVESICAL BILE DUCT DURING LAPAROSCOPIC CHOLECYSTECTOMY
Authors: Filip S.S. , Skrypynets Y.P. , Voronych V.M. , Shitev A.I. , Alzubaidi H.B. 
Published: April 2023

Introduction. Subvesical bile ducts (Lyushka ducts) are tubular aberrant anatomical anomalies of the biliary tree, in which the intrahepatic bile ducts drain into the lumen of the gallbladder at different levels.
According to various sources, this variant of the anatomical architecture of the bile ducts occurs in 1.7 - 3% of clinical cases.
The relevance of knowing the anatomical features of the biliary tree is due to the fact that routine preoperative methods of examination in most cases do not allow to verify them, and unnoticed damage to such courses at the stage of extraction of the bile duct can lead to intraoperative and postoperative complications.
Therefore, knowledge of the presence of such anatomical options is a condition for safe laparoscopic cholecystectomy (LC).
Goal. To represent a clinical case of aberrant subvesical bile duct during LC.
Presentation of a clinical case. The 41-year-old patient was hospitalized for acute biliary pancreatitis of mild severity according to the Ranson scale against the background of gallstone disease. In cooperation with related specialists, the patient underwent complex conservative treatment according to the updated recommendations for the management of acute pancreatitis (AP). After the normalization of basic laboratory indicators, exclusion of local parapancreatic complications, the patient was prepared for LC. Intraoperatively, a subvesical aberrant bile duct with a diameter of 1 mm was found, connecting the lumen of the gallbladder with the intrahepatic ducts of the IV segment of the liver. Coagulation of the bilious source was performed. A diagnostic tubular drainage was installed. No complications were observed in the early and late postoperative period.
Discussion. Subvesical bile ducts, or "Lyushka's ducts" - anatomical variants of biliary tracts that flow directly into the gallbladder, perforating its wall at different levels.
The etiology of Lyushka's movements is a subject of debate. The first theory describes them as an embryological abnormality of development in the early stages of embryogenesis. In our clinical case, it is quite likely that subvesical bile ducts could have arisen according to the second theory - hypertrophy of parenchymal branches as a result of previous local inflammation against the background of chronic cholecystitis and periodic exacerbation of cryptogenic hepatitis.
Due to their small size, these movements can go unnoticed, causing various postoperative complications. Therefore, such ducts are of great clinical importance for surgeons. Their preoperative identification is often impossible, so they can be damaged intraoperatively.
Bile leakage due to damage to aberrant ducts usually manifests itself clinically within the first postoperative week. In severe cases, the development of biliary peritonitis with subsequent sepsis is possible.
In our case, cholelithiasis from the subvesical course was eliminated by coagulation. In cases of postoperative complications, according to the literature, endoscopic methods are the main method of treatment. A repeat laparotomy is very rarely necessary.
Conclusions. Aberrant subvesical bile ducts are extremely rare and may be overlooked during hepatobiliary operations. Their damage occurs at the stage of separation of the ZHM from its bed and is therefore inevitable. Knowledge of their existence, intraoperative vigilance and delicate surgical technique allow to identify and timely prevent the development of complications.