Cholecystectomy revealing a cystic artery draining directly onto the gallbladder body: a case report and surgical implications

Abstract

Abstract Background Laparoscopic cholecystectomy is one of the most commonly performed surgical procedures worldwide for symptomatic cholelithiasis. Safe execution requires precise identification of both biliary and vascular anatomy. However, the cystic artery exhibits considerable anatomical variability, with non-standard courses reported in a significant proportion of patients. Arterial variants located outside Calot’s triangle are associated with increased risks of intraoperative hemorrhage and biliary injury. Several classifications have been proposed to categorize these variations, including arteries arising from hepatic parenchyma or inserting directly into the gallbladder body, patterns that significantly modify surgical strategy. Case presentation A 45-year-old woman presented with recurrent right upper quadrant abdominal pain secondary to symptomatic gallstone disease. Preoperative ultrasound confirmed cholelithiasis without signs of acute cholecystitis or bile duct dilation. During elective laparoscopic cholecystectomy, careful dissection to obtain the critical view of safety revealed an anomalous cystic artery arising from the hepatic parenchyma and inserting directly onto the body of the gallbladder rather than within Calot’s triangle. The artery was meticulously skeletonized, clipped at its gallbladder insertion, and divided safely. The remainder of the procedure was uneventful. The patient had an uncomplicated postoperative course and was discharged on postoperative day two, with no complications at two-month follow-up. Conclusion Direct insertion of the cystic artery into the gallbladder body is a rare but potentially hazardous anatomical variant. This case highlights the critical importance of systematic dissection, strict adherence to the critical view of safety, and controlled arterial clipping to prevent vascular and biliary complications. Awareness of such variants is essential to ensure optimal patient safety during laparoscopic cholecystectomy. Learning Points The cystic artery demonstrates significant anatomical variability with direct implications for intraoperative safety, exposing the patient to a risk of major hemorrhage and biliary injury if misidentified. Direct insertion of the cystic artery into the gallbladder body represents a rare but high-risk anatomical variant, as it may mimic a hepatic arterial branch and be inadvertently divided. Strict achievement of the critical view of safety remains mandatory, even in the presence of atypical vascular anatomy, before division of any tubular structure. Dissection must be meticulous, with full skeletonization of the artery up to its point of insertion into the gallbladder wall, and clips should be applied as close to the gallbladder as possible to prevent hepatic vascular injury. Early conversion to an open approach should be regarded as a safety strategy rather than a failure, particularly when vascular control or anatomical exposure is uncertain.