WP3.3 - Surgical Management of multiple mega large stones of a congenitally low inserted Cystic Duct – A Case Report

Abstract Introduction Low cystic duct insertion is uncommon, and the presence of multiple large stones in the cystic duct with normal laboratory investigation is rare. The infrequency with which it is encountered and the management done makes this an interesting presentation. Case presentation A 61-year-old female with incidental gall stones and possible CBD/cystic duct stones on a CTAP during a workup for management of an incisional hernia of the abdomen. The patient initially presented with abdominal pain that was thought to be due to the incisional hernia. On examination, the patient had a soft abdomen with no jaundice and normal laboratory investigations. MRCP scan demonstrated multiple gall stones and cystic duct stones suggestive of Mirizzi syndrome. The patient underwent laparoscopic repair of the incisional hernia and cholecystectomy with an on-table cholangiogram. Cholangiogram showed a low inserting cystic duct joining the common hepatic duct at the sphincter of Oddi with an almost nonexistent common bile duct and a cystic duct containing multiple mega-large stones. The cystic duct was explored and stones were milked out except the most inferior stone which was impacted at the sphincter of Oddi. This was dislodged with a Fogarty catheter and all stones were retrieved. Completion cholangiogram demonstrated complete clearance of the biliary tree with dye entering the duodenum. The patient recovered well postoperatively with no complications at 1 month post-operative. Conclusion This case illustrates a rare presentation of large cystic duct stones in the presence of abnormal anatomy and provides an option for surgical management.