duplication of the common bile duct ( cbd ) is an extremely rare congenital anomaly .
duplication of the intrahepatic biliary system is more common with a reported prevalence of 15% ,   while double common bile duct ( dcbd ) has been reported only 24 times in the western literature before 1986 .
though dcbd is rarely reported , it is an important condition to note because dcbd is associated with biliary lithiasis , choledocholithiasis , cholangitis , pancreatitis and upper gastrointestinal malignancies .
variations of the biliary tract , including dcbd , increase the risk of bile duct injury ( bdi ) during procedures such as laparoscopic cholecystectomy .
the patient is a 79-year - old white man who had a laparoscopic converted to open cholecystectomy performed approximately 3 weeks before transfer to our facility .
the cholecystectomy was performed using a retrograde fundus - down approach , with inability to obtain the critical view .
a tubular structure , thought to be a duct of luschka , was also identified and ligated in addition to the cystic artery and duct .
a single drain was placed , and the procedure was completed in an otherwise standard fashion .
he returned to the outside facility approximately 4 days later with jaundice , weakness , fatigue and pain .
a computed tomography ( ct ) scan of the abdomen and a nuclear cholescintigraphy scan confirmed a biliary leak with free intra - abdominal fluid consistent with biliary peritonitis ( fig .
the patient was placed on broad spectrum antibiotics and treated for atrial fibrillation with rapid ventricular response .
laboratory workup revealed a bilirubin level of 17  mg / dl , as well as profound protein 
a percutaneous cholangiogram was performed confirming a hilar ligation of his hepatic duct with inability to pass a wire or catheter distally . a right posterior and
the patient was then managed with high calorie , high protein enteral nutrition through a nasogastric dobhoff tube for approximately 7 days until able to tolerate appropriate oral intake for discharge .
cholangiogram of right intrahepatic ducts with abrupt cutoff at surgical clips . at follow - up , the patient had improved substantially .
his bilirubin improved to 1.2  mg / dl with an albumin of 3.1  gm / dl and prealbumin of 17.3  gm / dl . at this visit
, he was scheduled for definitive biliary reconstruction approximately 2 months after his initial operation . during this operation ,
the porta was dissected and the common and proper hepatic arteries were identified and preserved . we were unable to palpate the previously placed percutaneous biliary catheters due to the high placement above the hilum at the level of multiple clips .
we transected the cbd distally and removed numerous clips , finally noting bile drainage , but were unable to identify a cholangiogram catheter .
an on - table cholangiogram with fluoroscopy was performed noting two separate extrahepatic biliary systems , draining the right and left lobes of the liver , respectively ( figs 3 and 4 ) .
both distal ducts were ligated to definitively close the orifice to the duodenum and prevent spillage .
a roux limb of jejunum was created and anastomosed in a retrocolic fashion to the two separate hepatic ducts at the level of the hilum .
figure 3:intraoperative cholangiogram of the right ductal system through the extrahepatic right cbd . 
 figure 4:intraoperative cholangiogram of the left ductal system through the extrahepatic left cbd .
the patient was discharged  on postoperative day 6 with normal hepatic function , normal bilirubin and no further complications .
a follow - up cholangiogram at his postoperative clinic visit showed normal intrahepatic ducts with no evidence of stricture or leak , signifying successful repair of his injury with bypass of his duplicated biliary anatomy ( fig .
his cholangiogram catheters were removed , and he was discharged from the clinic . 
 figure 5:postoperative cholangiogram with two separate hepaticojejunostomy anastomoses of the right and left intrahepatic bile ducts .
postoperative cholangiogram with two separate hepaticojejunostomy anastomoses of the right and left intrahepatic bile ducts .
awareness of variations in the extrahepatic biliary ducts is critical in order to facilitate appropriate surgical planning and minimize  bdi .
inability to correctly identify the cystic duct and  cbd can lead to mistaking the cbd for the cystic duct and inadvertently transecting the cbd .
in addition , anomalous biliary anatomy , such as a duplicated biliary system , portends higher risk of inadvertent biliary injury , most commonly due to the inability to identify expected anatomical structures .
the current classification system of the dcbd includes the following configurations : ( i ) cbd with septum within the lumen , ( ii ) cbd that bifurcates and drains separately , ( iii ) double biliary drainage without extrahepatic communication ( includes subtypes ( a ) without or ( b ) with intrahepatic communicating channels ) , ( iv ) double biliary drainage with one or more extrahepatic communicating channels and ( v ) single biliary drainage of double extrahepatic bile ducts ( a ) without or ( b ) with communicating channels . knowledge of these configurations is important in order to prevent bdi .
various biliary pathologies are found to be associated with biliary tree anomalies . reviewing the literature ,
cholelithiasis is seen in 28% of cases , choledochal cyst in 11% , anomalous union of the pancreaticobiliary ductal system  in 30% and cancer in 26% .
the site of opening of the anomalous common bile duct ( acbd ) is the most important clinical feature of the dcbd , as the acbd opening location tends to correspond with the type of biliary pathology found .
importantly , gastric cancer is an associated complication in patients with the acbd opening in the stomach , while gallbladder cancer and ampullary cancer tend to occur in patients with acbd openings in the second portion of the duodenum and the pancreatic duct .
the origin of these biliary abnormalities is believed to be due to disturbances with recanalization in the hepatic primordium . in conclusion , bdi is a relatively common occurrence during difficult laparoscopic and open cholecystectomy procedures .
though inflammation and intraductal stones can certainly complicate cholecystectomy procedures , anomalous extrahepatic biliary anatomy is also an important factor that may increase the risk of iatrogenic bile duct injuries .
this case represents the successful management of an iatrogenic bdi due to aberrant biliary anatomy including appropriate preoperative biliary diversion , control of biliary peritonitis and intra - abdominal sepsis , aggressive nutritional supplementation and appropriate biliary reconstruction at an experienced hepatobiliary surgery center .
 though variations of intrahepatic biliary anatomy are quite common , duplication of the extrahepatic biliary system is extremely rare and reported infrequently in the literature . 
 laparoscopic cholecystectomy is one of the most common general surgery procedures performed . 
 unfortunately , iatrogenic bile duct injuries can contribute to significant morbidity including hospital readmissions , infectious complications and death . 
 anomalous extrahepatic biliary anatomy may be one of the factors , which increases the likelihood of bile duct injury during laparoscopic cholecystectomy . 
 we present a case of an iatrogenic bile duct injury that occurred during a laparoscopic cholecystectomy , in which a duplicated extrahepatic biliary system was identified intraoperatively during the definitive operative repair . 
Introduction
Case Report
Discussion
Conflict of Interest Statement