The gallbladder is a pear-shaped sac, about 7 to 10 cm long, with an average capacity of 30 to 50 mL.

When obstructed, the gallbladder can distend markedly and contain up to 300 mL.1 The gallbladder
is located in a fossa on the inferior surface of the liver. A line from this fossa to the inferior vena cava
divides the liver into right and left liver lobes. The gallbladder is divided into four anatomic areas: the
fundus, the corpus (body), the infundibulum, and the neck. The fundus is the rounded, blind end
that normally extends 1 to 2 cm beyond the liver’s margin. It contains most of the smooth muscles of
the organ, in contrast to the body, which is the main storage area and contains most of the elastic
tissue. The body extends from the fundus and tapers into the neck, a funnel-shaped area that
connects with the cystic duct. The neck usually follows a gentle curve, the convexity of which may be
enlarged to form the infundibulum or Hartmann’s pouch. The neck lies in the deepest part of the
gallbladder fossa and extends into the free portion of the hepatoduodenal ligament (Fig. 32-1). The
same peritoneal lining that covers the liver covers the fundus and the inferior surface of the
gallbladder. Occasionally, the gallbladder has a complete peritoneal covering and is suspended in a
mesentery off the inferior surface of the liver, and rarely, it is embedded deep inside the liver
parenchyma (an intrahepatic gallbladder).

The gallbladder is lined by a single, highly folded, tall columnar epithelium that contains cholesterol
and fat globules. The mucus secreted into the gallbladder originates in the tubuloalveolar glands
found in the mucosa lining the infundibulum and neck of the gallbladder, but are absent from the
body and fundus. The epithelial lining of the gallbladder is supported by a lamina propria. The
muscle layer has circular longitudinal and oblique fibers, but without well-developed layers. The
perimuscular subserosa contains connective tissue, nerves, vessels, lymphatics, and adipocytes. It is
covered by the serosa except where the gallbladder is embedded in the liver. The gallbladder differs
histologically from the rest of the gastrointestinal (GI) tract in that it lacks a muscularis mucosa and
submucosa. The cystic artery that supplies the gallbladder is usually a branch of the right hepatic
artery (>90% of the time). The course of the cystic artery may vary, but it nearly always is found
within the hepatocystic triangle, the area bound by the cystic duct, common hepatic duct, and the
liver margin (triangle of Calot). When the cystic artery reaches the neck of the gallbladder, it divides
into anterior and posterior divisions. Venous return is carried either through small veins that enter
directly into the liver or, rarely, to a large cystic vein that carries blood back to the portal vein.
Gallbladder lymphatics drain into nodes at the neck of the gallbladder. Frequently, a visible lymph
node overlies the insertion of the cystic artery into the gallbladder wall. The nerves of the
gallbladder arise from the vagus and from sympathetic branches that pass through the celiac plexus.

1 The physiology of the gallbladder and sphincter of Oddi is regulated by a complex interplay of
hormones and neuronal inputs designed to coordinate bile release with food consumption.
Dysfunctions related to this activity are linked to the development of gallbladder pathologies
described in this chapter. 2 In Western countries, the most common type of gallstones are
cholesterol stones. The pathogenesis of these stones relates to supersaturation of bile with
cholesterol and subsequent precipitation. 3 Laparoscopic cholecystectomy has been demonstrated
to be a safe and effective alternative to open cholecystectomy and has become the treatment of
choice for symptomatic gallstones. Knowledge of the various anatomic anomalies of the cystic duct
and artery is helpful in guiding the dissection of these structures as well as avoiding injury to the
common bile duct during cholecystectomy. 4 Common bile duct injuries, although uncommon, can
be devastating to patients. Proper exposure of Calot’s triangle and careful identification of the
anatomic structures are keys to avoiding these injuries. Once a bile duct injury is diagnosed, the best
outcomes are seen at large referral centers with experienced biliary surgeons. 5 The main risk factor
for gallbladder disease in Western countries is cholelithiasis. The main complications include
cholecystitis, choledocholithiasis, cholangitis, and biliary pancreatitis. In addition, cholelithiasis plays
the role as the major risk factor for the development of gallbladder cancer. 6 Carcinoma of the
gallbladder and bile duct generally have a poor prognosis because patients usually present late in
the disease process and have poor response to chemotherapy and radiation therapy. Surgery offers
the best chance for survival and has good long-term survival in patients with early-stage disease.

The preganglionic sympathetic level is T8 and T9. Impulses from the liver, gallbladder, and the bile
ducts pass by means of sympathetic afferent fibers through the splanchnic nerves and mediate the
pain of biliary colic. The hepatic branch of the vagus nerve supplies cholinergic fibers to the
gallbladder, bile ducts, and liver. The vagal branches also have peptide-containing nerves containing
agents such as substance P, somatostatin, enkephalins, and vasoactive intestinal polypeptide.

The extrahepatic bile ducts consist of the right and left hepatic ducts, the common hepatic duct, the
cystic duct, and the common bile duct or choledochus. The common bile duct enters the second
portion of the duodenum through a muscular structure, the sphincter of Oddi.3 The left hepatic duct
is longer than the right and has a greater propensity for dilatation as a consequence of distal
obstruction. The two ducts join to form a common hepatic duct, close to their emergence from the
liver. The common hepatic duct is 1 to 4 cm in length and has a diameter of approximately 4 mm. It
lies in front of the portal vein and to the right of the hepatic artery. The common hepatic duct is
joined at an acute angle by the cystic duct to form the common bile duct. The length of the cystic
duct is quite variable. It may be short or absent and have a high union with the hepatic duct, or long
and run parallel, behind, or spiral to the main hepatic duct before joining it, sometimes as far as at
the duodenum. Variations of the cystic duct and its point of union with the common hepatic duct are
surgically important (Fig. 32-2). The segment of the cystic duct adjacent to the gallbladder neck
bears a variable number of mucosal folds called the spiral valves of Heister. They do not have any
valvular function but may make cannulation of the cystic duct difficult. The common bile duct is
about 7 to 11 cm in length and 5 to 10 mm in diameter. The upper third (supraduodenal portion)
passes downward in the free edge of the hepatoduodenal ligament, to the right of the hepatic artery
and anterior to the portal vein. The middle third (retroduodenal portion) of the common bile duct
curves behind the first portion of the duodenum and diverges laterally from the portal vein and the
hepatic arteries. The lower third (pancreatic portion) curves behind the head of the pancreas in a
groove, or traverses through it and enters the second part of the duodenum. There, the pancreatic
duct frequently joins it. The common bile duct runs obliquely downward within the wall of the
duodenum for 1 to 2 cm before opening on a papilla of mucous membrane (ampulla of Vater), about
10 cm distal to the pylorus. The union of the common bile duct and the main pancreatic duct follows
one of three configurations. In about 70% of people, these ducts unite outside the duodenal wall
and traverse the duodenal wall as a single duct. In about 20%, they join within the duodenal wall and
have a short or no common duct, but open through the same opening into the duodenum. In about
10%, they exit via separate openings into the duodenum. The sphincter of Oddi, a thick coat of
circular smooth muscle, surrounds the common bile duct at the ampulla of Vater (Fig. 32-3). It
controls the flow of bile, and in some cases pancreatic juice, into the duodenum. The extrahepatic
bile ducts are lined by a columnar mucosa with numerous mucous glands in the common bile duct. A
fibroareolar tissue containing scant smooth muscle cells surrounds the mucosa. A distinct muscle
layer is not present in the human common bile duct. The arterial supply to the bile ducts is derived
from the gastroduodenal and the right hepatic arteries, with major trunks running along the medial
and lateral walls of the common duct (sometimes referred to as 3 o’clock and 9 o’clock). These
arteries anastomose freely within the duct walls. The density of nerve fibers and ganglia increases
near the sphincter of Oddi, but the nerve supply to the common bile duct and the sphincter of Oddi
is the same as for the gallbladder.

The classic description of the extrahepatic biliary tree and its arteries applies only in about one third
of patients.4 The gallbladder may have abnormal positions, be intrahepatic, be rudimentary, have
anomalous forms, or be duplicated. Isolated congenital absence of the gallbladder is very rare, with
a reported incidence of 0.03%. Before the diagnosis is made, the presence of an intrahepatic bladder
or anomalous position must be ruled out. Duplication of the gallbladder with two separate cavities
and two separate cystic ducts has an incidence of about one in every 4000 persons. This occurs in
two major varieties: the more common form in which each gallbladder has its own cystic duct that
empties independently into the same or different parts of the extrahepatic biliary tree, and as two
cystic ducts that merge before they enter the common bile duct. Duplication is only clinically
important when some pathologic processes affect one or both organs. A left-sided gallbladder with a
cystic duct emptying into the left hepatic duct or the common bile duct and a retrodisplacement of
the gallbladder are both extremely rare. A partial or totally intrahepatic gallbladder is associated
with an increased incidence of cholelithiasis. Small ducts (of Luschka) may drain directly from the
liver into the body of the gallbladder. If present, but not recognized at the time of a
cholecystectomy, a bile leak with the accumulation of bile (biloma) may occur in the abdomen. An
accessory right hepatic duct occurs in about 5% of cases. Variations of how the common bile duct
enters the duodenum are described in earlier, in the Bile Ducts section. Anomalies of the hepatic
artery and the cystic artery are quite common, occurring in as many as 50% of cases.5 In about 5% of
cases, there are two right hepatic arteries, one from the common hepatic artery and the other from
the superior mesenteric artery. In about 20% of patients, the right hepatic artery comes off the
superior mesenteric artery. The right hepatic artery may course anterior to the common duct. The
right hepatic artery may be vulnerable during surgical procedures, in particular when it runs parallel
to the cystic duct or in the mesentery of the gallbladder. The cystic artery arises from the right
hepatic artery in about 90% of cases, but may arise from the left hepatic, common hepatic,
gastroduodenal, or superior mesenteric arteries.