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Fig 2. Schematic view of main variations of the biliary system anatomy in thetriangle of Calot and the gallbladder fossa. (A) Duct of Luschka, (B)cystohepatic duct, (C) vaginali ductuli, (D) variant drainage of right posteriorsector, (E) duplication of cystic duct, (F) duplication of gallbladder. CD, cysticduct; DL, duct of Luschka; CHD, cystohepatic duct; CBD, common bile duct;RBD, right bile duct; GB, gallbladder; VD, vaginali ductuli.

Bile ducts of Luschka (also called supravesicular ducts) are small bile ducts inthe gallbladder bed. Although they do not drain any liver parenchyma, theycan be a source of bile leak or biliary peritonitis after cholecystectomy in bothadults and children, as shown in this case report.

Gallstone disease remains the most common disease of the digestive systemin Western societies and laparoscopic cholecystectomy one of the mostcommon surgical procedures performed. Bile leaks remain a significant causeof morbidity for patients undergoing this procedure. These occur in 0.2-2% of

cases. The bile ducts of Luschka, or subvesical ducts, are small ducts whichoriginate from the right hepatic lobe, course along the gallbladder fossa, andusually drain in the extrahepatic bile ducts. Injuries to these ducts are thesecond most frequent cause of postcholecystectomy bile leaks.

A literature search using MEDLINE's Medical Subject Heading terms was usedto identify recent articles. Cross-references from these articles were also

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used.

Subvesical bile duct leaks can be detected by drip-infusion cholangiographyusing computed tomography preoperatively, direct visualization or

cholangiography intraoperatively, and fistulography, endoscopic retrogradecholangiopancreatography (ERCP), and magnetic resonancecholangiopancreatography with intravenous contrast postoperatively. ERCP isthe most common diagnostic method used. Most patients with subvesicalduct leaks are symptomatic, and most leaks will be detected postoperativelyduring the first postoperative week. Drainage of extravasated bile ismandatory in all cases. Reduction of intrabiliary pressure with endoscopicsphincterotomy and stent placement will lead to preferential flow of bilethrough the papilla, thus permitting subvesical duct injuries to heal. This isthe most common treatment modality used. In a minority of patients,relaparoscopy is performed. In such cases, the leaking subvesical duct isvisualized directly, and ligation usually is sufficient treatment. Simple

drainage is adequate treatment for a small number of asymptomatic patientswith low-volume leaks.

Subvesical duct leaks occur after cholecystectomy regardless of gallbladderpathology or urgency of operation. They have been encountered morefrequently in the era of laparoscopic cholecystectomy. Intraoperativecholangiography does not detect all such leaks. Staying close to thegallbladder wall during its removal from the fossa is the only knownprophylactic measure. ERCP and stent placement are the most commoneffective diagnostic and therapeutic methods used. Intraoperative and

perioperative adjunctive measures, such as fibrin glue instillation andpharmacologic relaxation of the sphincter of Oddi, can potentially be used inlowering the incidence of subvesical bile leaks.