What are spiral valves in cholecystectomy?

Spiral Valves in Cholecystectomy

Spiral valves, also known as Heister valves, are mucosal folds located on the endoluminal surface of the cystic duct that can impact surgical technique during cholecystectomy by potentially impeding transcystic exploration. 1

Anatomy and Characteristics

• Heister valves were first described by Lorenz Heister in 1732 and are present in most cystic ducts

• Key characteristics include:

  • Typically distributed uniformly on the cystic duct
  • Usually present in an oblique disposition
  • Most commonly follow a nonreticular pattern (particularly B1 subtype) 1
  • Previously thought to follow a steady rhythmic spiral pattern, but research has shown their distribution lacks a conclusive systematic pattern 1

• The cystic duct has an average length of 25.37 mm and diameter of 4.53 mm, with Heister valves present in most cases 1

Surgical Significance During Cholecystectomy

Impact on Surgical Technique

• These valves can represent an obstacle during transcystic exploration, potentially complicating:

  • Intraoperative cholangiography (IOC)
  • Transcystic common bile duct exploration
  • Stone removal from the cystic duct

• When cystic duct stones are encountered (occurs in approximately 12.3% of laparoscopic cholecystectomies), the spiral valves may complicate stone extraction 2

Management Considerations

• During laparoscopic cholecystectomy, surgeons should be aware that:
  • The cysticotomy incision should not be determined by the distribution of the valves on the cystic duct 1
  • Heister valves may necessitate additional manipulation when performing IOC or transcystic exploration
  • In cases where stones are impacted behind these valves, incision of the duct over the stone may be required 2

Relevance to Bile Duct Injury Prevention

• Understanding the cystic duct anatomy, including Heister valves, is crucial for safe cholecystectomy

• The Critical View of Safety (CVS) technique is recommended to minimize iatrogenic complications by:

  • Clearing the hepatocystic triangle from fat and fibrous tissue
  • Identifying only two structures entering the gallbladder (cystic duct and cystic artery)
  • Visualizing the lower third of the gallbladder dissected from the liver bed 3

• Awareness of anatomical variants is essential, as biliary ductal anomalies of surgical importance occur in approximately 10% of patients 4

Recommendations for Safe Practice

• When encountering difficulties with transcystic exploration due to spiral valves:

  • Consider intraoperative cholangiography to define biliary anatomy when anatomy is unclear 3
  • Be particularly cautious with short cystic ducts or spiral entry of the cystic duct into the common bile duct, as these configurations increase risk of bile duct injury 4
  • If cystic duct stones are encountered, IOC becomes mandatory as approximately 35% may be associated with bile duct stones 2

• When the CVS cannot be achieved and biliary anatomy cannot be clearly defined, consider alternative techniques such as:

  • "Fundus-first" (top-down) approach
  • Subtotal cholecystectomy
  • Conversion to open procedure when necessary for patient safety 5, 3

By understanding the presence and implications of spiral valves in the cystic duct, surgeons can better navigate potential challenges during cholecystectomy and reduce the risk of bile duct injury, which remains one of the most serious complications of this common procedure.