Intrahepatic lithiasis managed with hepatectomy and anterograde cholangioscopy through the right posterior sectorial duct

Intrahepatic lithiasis, endemic in East Asia, is increasing in Western countries and without proper treatment, may cause cholangitis, liver abscesses, biliary cirrhosis, and cholangiocarcinoma. Management may require endoscopic, percutaneous, or surgical approach to the bile duct. Anterograde approach through the stump of the biliary duct during hepatectomy has been reported only rarely. We present a case managed through an anterograde approach, which is a valid alternative that preserves the integrity of the main biliary tree. A 76-year-old woman presented with recurrent severe cholangitis episodes and intrahepatic lithiasis in the right posterior sectorial bile duct, with a dominant stone in the junction with the left duct. Due to a variation in the biliary tree anatomy, the retrograde access was difficult and after undergoing several unsuccessful attempts at endoscopic clearance, she was offered surgical therapy. Right posterior sectionectomy and common bile duct anterograde exploration through the stump were performed, for stones clearance. The anterograde approach allowed complete hepaticolitothomy, preserving the main biliary tree and preventing anastomotic stricture or leakage. This technique should be considered in sectorial limited intrahepatic lithiasis with steep angle of drainage, unapproachable by retrograde access.