Low insertion of hepatic segmental duct VII-VIII is an important cause of major biliary injury or misdiagnosis

BACKGROUND: The importance of variant anatomy is only mentioned generally in most articles in this era of laparoscopic cholecystectomy. We report a series of 14 patients in whom a seemingly low insertion of hepatic segmental duct VII-VIII was clinically important. METHODS: The patients were managed at Duke University Medical Center. Two intraoperative videotapes of injury were reviewed. RESULTS: Three categories of patients were identified: 6 patients who had injury in association with another major injury to the biliary system, 7 patients who had an isolated VII-VIII system injury, and 1 patient with a Klatskin tumor in whom the unobstructed variant duct was stented. After appropriate evaluation, all patients were successfully treated. Several lawsuits resulted, even when the injury was seemingly minor. Symptoms developed in all patients who filed lawsuits. but none in those who did not. CONCLUSION: Appreciation of the VII-VIII biliary variant can lead to avoidance of injury or to a successful repair. The injury can easily occur despite ''normal'' cholangiography. Successful clinical outcome does not necessarily correlate with freedom from lawsuits.