# Surgical Challenges Posed by Anomalous Biliary Tree Anatomy in Choledochal Cyst Excision: A Case Report

## TL;DR

A rare case of choledochal cyst with unusual anatomy highlights the surgical challenges and the need for intraoperative adjustments.

## Contribution

This case report presents a rare combination of Type 4a and Type 6 choledochal cyst requiring intraoperative modifications.

## Key findings

- The patient had a rare combination of Type 4a and Type 6 choledochal cyst.
- Intraoperative findings required a double bilioenteric anastomosis.
- Preoperative imaging did not fully predict the intraoperative complexity.

## Abstract

A choledochal cyst (CC) usually presents with abdominal pain, jaundice, and a palpable abdominal mass. CC usually results in complications like cystolithiasis, choledocholithiasis, pancreatitis, liver cirrhosis, and intracystic stones, which are particularly more common in Type 4 CC. Here we present a rare case of Type 4a and Type 6 CC in a 21-year-old female patient who presented to us with complaints of acute onset of jaundice and pain in the abdomen. She was evaluated preoperatively with magnetic resonance cholangiopancreaticography (MRCP) and subsequently planned for excision of the cyst with hepaticojejunostomy as a definite mode of management. Intraoperative findings required a double bilioenteric anastomosis. This case emphasizes that in spite of preoperative imaging and radio-diagnosis, the intraoperative findings may differ. Hence, a surgeon should be mentally prepared to do intraoperative biliary tree exploration and modify the treatment plan accordingly.