YL5: 08.

18 Gross Anatomy of the Gallbladder

01/21/2019 Gastrointestinal System and Nutrition
10:00-12:00 Michele P. Rivera-Nuez, MD, FPCS, FPAPRAS

TABLE OF CONTENTS • Posteriorly

→ Epiploic foramen of Winslow or omental foramen
I. TOPOGRAPHY ............................................................................................. 1 ▪ The space behind the hepatoduodenal ligament
A. SPATIAL ORIENTATION ................................................................... 1 ▪ Leads to the omental bursa or lesser sac
II. GENERAL FEATURES OF THE GALLBLADDER .................................... 1
III. PARTS OF THE GALLBLADDER .............................................................. 2
A. FUNDUS ............................................................................................. 2
B. BODY .................................................................................................. 2
C. NECK .................................................................................................. 2
IV. RELATIONS ................................................................................................ 2
V. BILIARY TREE............................................................................................. 2
A. CYSTIC DUCT .................................................................................... 2
B. COMMON BILE DUCT ....................................................................... 2
VI. NEUROVASCULATURE ............................................................................ 3
A. ARTERIAL BLOOD SUPPLY ............................................................. 3
B. VENOUS BLOOD DRAINAGE .......................................................... 3
C. LYMPHATIC DRAINAGE ................................................................... 3
D. INNERVATION ................................................................................... 4
VII. CLINICAL CORRELATIONS .................................................................... 4
A. WANDERING GALLBLADDER ......................................................... 4
B. GALLSTONE/CHOLELITHIASIS ....................................................... 4
C. BILIARY COLIC (GALLBLADDER ATTACK) ................................... 4 Figure 2. Hepatoduodenal ligament and foramen of Winslow
D. MIRRIZI SYNDROME ........................................................................ 4
E. CHOLECYSTO-ENTERIC FISTULA ................................................. 4 Cystic Plate
F. GALLSTONE ILEUS ........................................................................... 4
G. BOUVERET SYNDROME ................................................................. 4
VIII. SURGICAL CONSIDERATIONS ............................................................. 5
A. CHOLECYSTECTOMY ...................................................................... 5
B. DUCTS OF LUSCHKA ....................................................................... 5
C. VARIATIONS IN THE CYSTIC & HEPATIC DUCT .......................... 5
D. ACCESSORY HEPATIC DUCTS ...................................................... 5
QUICK REVIEW ............................................................................................... 5
SUMMARY OF TERMS .......................................................................... 5
REVIEW QUESTIONS ............................................................................ 5

I. TOPOGRAPHY
A. SPATIAL ORIENTATION
• The gallbladder is located at the junction of the right 9th costal
cartilage and the lateral border of the rectus abdominis
→ Situated at the right upper quadrant of the abdomen Figure 3. Cystic plate
→ Projected into the anterior abdominal wall usually at the right
parasternal line • The fibroareolar tissue that separates the gallbladder from the
• The gallbladder can be found on the inferior surface of the liver on liver parenchyma
the gallbladder fossa • Small ducts may drain from the liver parenchyma into the
→ This shallow fossa is used as a reference point to determine gallbladder from the cystic plate
the boundary of the left and right lobes of the liver → These ducts are called the ducts of Luschka
• Inferior portion of the gallbladder is covered in peritoneum
whereas the superior side is no Liver Segments
• Cholecystoduodenal fold
→ Connects the gallbladder to the first part of the duodenum
• The body of the gallbladder lies anterior to the superior part of
the duodenum, and its neck and cystic duct are immediately
superior to the duodenum

Figure 4. Liver segments

• The gallbladder is situated between segments IVb and V of the

liver

II. GENERAL FEATURES OF THE GALLBLADDER

Figure 1. Sagittal view of the liver • Shape: piriform or pear-shaped
• Size: 7-10 cm long lying along the visceral surface of the Liver
• Posteromedial • Capacity: it has a storage of 30-50 mL
→ Hepatoduodenal ligament • Thickness: 2.6 ± 1.6 mm
▪ Free right edge of the lesser omentum, which runs from • Volume Measurements: 242 ± 234 mL
the posterior surface of the liver to the lesser curvature
of the stomach and the first part of the duodenum (2022
trans)

YL5: 08.18 Group 2: Creencia, Gesmundo, Leonida, Marchadesch, Michelena, Rementina, Tiu, Villa 1 of 6
 III. PARTS OF THE GALLBLADDER

Figure 5. Parts of the gallbladder

A. FUNDUS
• Anterior, rounded end-portion of the gallbladder
• Projects into the inferior surface of the liver
• Part of the gallbladder that can be palpated
B. BODY
• Largest part of the gallbladder
• Occasionally in contact with the transverse colon, visceral surface
of the liver and the proximal duodenum
• Contains the infundibulum
→ Narrowing portion of the body leading to the neck
C. NECK
• Narrow tapering end directed towards the porta hepatis
→ A deep fissure in the inferior surface of the liver containing
neurovascular structures
• Part where gallbladder become continuous with the cystic duct,
leading to the biliary tree
• Contains the Hartmann’s Pouch
→ Common location for gallstones to become lodged (causing
cholestasis)
IV. RELATIONS
• The gallbladder lies in close proximity to the following structures:
→ Superiorly: liver
→ Inferiorly: transverse colon, D2 (Descending) segment of
the duodenum
→ Anteriorly: 9th costal cartilage
Figure 7b. Biliary tree
• The ducts extend from the liver, communicate with the gallbladder
and pancreas, and end at the opening of the duodenum
• Begins with left and right hepatic ducts
→ Size: 6-8 cm in length, 6 mm in diameter
→ Drains bile from left and right portion of the liver, respectively
• Summary of biliary tree:
→ Left hepatic duct (bile from liver) + right hepatic duct (bile
from liver) → common hepatic duct
→ Common hepatic duct (bile from liver) + cystic duct (bile flow
in and out of gallbladder) → common bile duct
→ Common bile duct + main pancreatic duct →
hepatopancreatic ampulla / ampulla of Vater
A. CYSTIC DUCT
• Length: 3-4 cm long
• S-shaped duct, delivers concentrated bile to the duodenum
• Connects the neck of the gallbladder to the common hepatic duct,
forming the common bile duct
• Spiral valve
→ Also known as spiral fold
→ Keeps the lumen of the cystic duct open
▪ To allow easy passage of bile into the gallbladder when
the distal end of the bile duct is closed
→ Resists backflow of bile when the sphincters are closed
and intra-abdominal pressure is suddenly increased (like
during a sneeze or cough)

Figure 6. Relations of the gallbladder

V. BILIARY TREE

Figure 8. Cystic duct

B. COMMON BILE DUCT

• Also known as bile duct
• Length: varies between 5-15 cm
• Formed by the joining of the common hepatic duct and cystic
duct
• Transports biliary secretions from the liver and gallbladder to the
duodenum
Figure 7a. Biliary tree • Sphincter of the bile duct

YL5: 08.18 Gastrointestinal System and Nutrition: Gross Anatomy of the Gallbladder 2 of 6
 → Thickened section of circular muscle located around the Cystohepatic Triangle of Calot
distal end of the bile duct
→ Contraction results in:
▪ Preventing bile from entering the Ampulla of Vater and
duodenum
▪ Bile backflows along the cystic duct to the gallbladder
for concentration and storage

Course of the Common Bile Duct

• Can be split into three parts
→ First part
▪ Lies in the free margin of the lesser omentum
▪ In front of the epiploic foramen of Winslow and portal
vein
▪ Right of hepatic artery
→ Second part
▪ Found in D1 of the duodenum
▪ To the right of the gastroduodenal artery Figure 11. Cystic artery and triangle of Calot
→ Third part
▪ Situated in the groove of the posterior surface of the • Triangle whose sides are formed by:
head of the pancreas → Common Hepatic Duct
▪ Location where the bile duct joins the pancreatic duct, → Cystic Duct
and then enters the wall of D2 of the duodenum → Inferior surface of the Liver
▪ Terminates in the hepatopancreatic ampulla (aka
Ampulla of Vater) in the major duodenal papilla Cystic Artery Variations

Figure 12. Cystic artery variation

• Variations in the origin and course of the cystic artery occur in

24.5% of people (Daseler et al., 1947)
Figure 9. Course of the common bile duct → This is clinically significant during cholecystectomy which is
the surgical removal of the gallbladder
VI. NEUROVASCULATURE
B. VENOUS BLOOD DRAINAGE
A. ARTERIAL BLOOD SUPPLY
• The venous drainage from the neck of the gallbladder and
• The arterial supply of the gallbladder and cystic duct is from the
cystic duct flows via the cystic veins
cystic artery
• These small and usually multiple veins enter the liver directly or
→ The cystic artery commonly arises from the right hepatic
drain through the hepatic portal vein into the liver, after joining
artery in the triangle between the common hepatic duct,
the veins draining from the hepatic ducts, and proximal bile duct
cystic duct, and visceral surface of the liver
• The veins from the fundus and body of the gallbladder pass
▪ Also known as the cystohepatic triangle of Calot
directly into the visceral surface of the liver and drain into the
hepatic sinusoids
→ Because this is drainage from one capillary (sinusoidal) bed
to another, it constitutes an additional (parallel) portal
system (Moore et al, 2014)

C. LYMPHATIC DRAINAGE
• The lymphatic drainage of the gallbladder is to the hepatic lymph
nodes
→ This is often through cystic lymph nodes located near the
neck of the gallbladder
→ Efferent lymphatic vessels from these nodes pass to the
celiac lymph nodes

Figure 10. Arterial blood supply of the gallbladder and neighboring

structures

YL5: 08.18 Gastrointestinal System and Nutrition: Gross Anatomy of the Gallbladder 3 of 6
 → May be attributed to pregnancy, hormone replacement
therapy, etc.
• This can block any part of the biliary tree.
• Distal end of the hepatopancreatic ampulla is the part most
commonly affected by gallstone obstruction as it is the narrowest
biliary passage.
• Common causes:
→ Sugar imbalance
→ Estrogen Imbalance
→ Food allergies
→ Chronic stress
→ Low-fiber diet
→ Low stomach acid production
→ Obesity
→ Rapid weight loss
→ Low-fat diet

Figure 13. Arteries and lymphatic drainage of the gallbladder

D. INNERVATION
Figure 15. Gallstones

C. BILIARY COLIC (GALLBLADDER ATTACK)

• Occurs when a stone tries to pass the biliary tree (impacted
gallstone in the cystic duct)
• Pain is described as spasmodic because the stone is trying to
spasm its way out of the tree
→ Pain may last for hours

Figure 14. Nerves and veins of the biliary system (Moore et al, 2014)

• The gallbladder receives parasympathetic, sympathetic, and

sensory innervation
→ Celiac plexus delivers sympathetic innervation
→ Right phrenic nerve carries sensory fibers
→ Hepatic branch of the right vagus nerve delivers
parasympathetic innervation
• Parasympathetic stimulation produces contraction of the
gallbladder, and the secretion of bile into the cystic duct due to
relaxation of the sphincter of Oddi
→ The majority of this response is mediated by circulating
cholecystokinin as part of the gustatory response
VII. CLINICAL CORRELATIONS
A. WANDERING GALLBLADDER
• Instead of being invested in the peritoneum, a wandering
gallbladder is typically attached to surrounding structures only by
the cystic duct and its mesentery
• Emphasized by Doc
→ Normal gallbladder is intimately related with liver,
wandering gallbladder is not
→ Gallbladder experiences torsion
▪ Leads to compromised blood supply, possibly necrosis
• Occurs in approximately 4% of the population
B. GALLSTONE/CHOLELITHIASIS
• Described as ‘stones’ in the gallbladder
• Women twice as likely to develop these, as compared to men.
Figure 16. Biliary colic
D. MIRRIZI SYNDROME
• Key characteristics: chronic inflammation and fibrosis
• Gallstone becomes impacted at the cystic duct or neck of the
gallbladder (Hartmann's pouch) and causes erosion of the
common hepatic duct or common bile duct
• This causes obstruction
E. CHOLECYSTO-ENTERIC FISTULA
• Chronic inflammation that causes erosion between the
gallbladder & duodenum
F. GALLSTONE ILEUS
• Obstruction of intestine when gallstone passes through the
biliary tree or even through the fistula
• Usual location is 60 cm proximal to the ileocecal valve
G. BOUVERET SYNDROME
• Gallstone ileus and bouveret syndrome is caused by gastric
outlet obstruction
• Can occur when gallstone from cholecysto-enteric fistula enters
the proximal duodenum, thereby blocking the level of the
pylorus, which is the outlet of the stomach (gastric outlet
syndrome)
→ It can be considered a very proximal form of gallstone ileus
• Relieved by enterotomy: opening intestine to remove gallstone

YL5: 08.18 Gastrointestinal System and Nutrition: Gross Anatomy of the Gallbladder 4 of 6
• Common among elderly women
Figure 17. Bouveret syndrome
VIII. SURGICAL CONSIDERATIONS
A. CHOLECYSTECTOMY
• Surgical removal of a diseased gallbladder
• Right hepatic artery is structure in most danger in this
procedure
• Procedure:
→ Retract rectus abdominis laterally
→ Open peritoneum
→ Pack and retract bowel
→ Identify gallbladder at the tip of the 9th costal cartilage
→ Catch hold of fundus with sponge holding forceps
→ Identify calot triangle
→ Ligate cystic artery and cystic duct close to the gallbladder
→ Separate the gallbladder from liver
• Kocher Incision: incise at right upper quadrant of abdomen wall
B. DUCTS OF LUSCHKA
• Accessory hepatic/cholecystohepatic duct
→ Originates from right hepatic lobe, course along the
gallbladder fossa, and usually drain in extrahepatic bile
ducts
→ Significant because injuries to these ducts during
cholecystectomy is a frequent cause of bile leaks
C. VARIATIONS IN THE CYSTIC & HEPATIC DUCT
• Awareness of variations in arteries and bile duct formation is
important for surgeons when they ligate the cystic duct during
cholecystectomy (surgical removal of the gallbladder)
• Caterpillar Loop or Moynihan's Hump
→ When the right hepatic artery replaces the cystic artery
within the Calot's triangle, and it is tortuous and projects
forwards to the right of the CHD (like the back of a
caterpillar during progression), and forms a U-shape loop
with a short cystic artery arising from it
• Other Examples of Variation:
→ High union of the cystic and common hepatic ducts near the
porta hepatis
→ Low union of the cystic and common hepatic ducts,
resulting in a short bile duct which lies posterior (or even
inferior) to the superior portion of the duodenum
▪ In low union, the two ducts may also be joined by
fibrous tissue, making surgical clamping of the cystic
duct difficult without injuring the common hepatic duct
→ The cystic duct may spiral anteriorly over the common
hepatic duct before joining it on the left side
→ The cystic duct can be short or even absent
→ Free right edge of the lesser omentum, which runes from the
posterior surface of the liver to the lesser curvature of the
stomach and the first part of the duodenum (2022 trans)
• Epiploic foramen of Winslow or omental foramen
→ The space behind the hepatoduodenal ligament
→ Leads to the omental bursa or lesser sac
• Ducts of Luschka
→ Small ducts may drain from the liver parenchyma into the
gallbladder from the cystic plate
• Parts of the gallbladder
→ Fundus- can be palpated
→ Body-largest part
→ Neck
▪ Contains the Hartmann’s Pouch- common location for
gallstones to become lodged (causing cholestasis)
• Summary of biliary tree
→ Left hepatic duct (bile from liver) + right hepatic duct (bile
from liver) → common hepatic duct
→ Common hepatic duct (bile from liver) + cystic duct (bile flow
in and out of gallbladder) → common bile duct
→ Common bile duct + main pancreatic duct →
hepatopancreatic ampulla / ampulla of Vater
• Cystic duct
→ Connects the neck of the gallbladder to the common hepatic
duct, forming the common bile duct
• Spiral valve
→ Also known as spiral fold
→ Keeps the lumen of the cystic duct open
→ To allow easy passage of bile into the gallbladder when the
distal end of the bile duct is closed
→ Resists backflow of bile when the sphincters are closed
and intra-abdominal pressure is suddenly increased (like
during a sneeze or cough)
• Common bile duct
→ Transports biliary secretions from the liver and gallbladder to
the duodenum
• Sphincter of the bile duct
→ Thickened section of circular muscle located around the
distal end of the bile duct
→ Contraction results in:
▪ Preventing bile from entering the Ampulla of Vater and
duodenum
▪ Bile backflows along the cystic duct to the gallbladder
for concentration and storage
• Cystohepatic triangle of Calot
→ The triangle between the common hepatic duct, cystic
duct, and visceral surface of the liver
• Celiac plexus delivers sympathetic innervation
• Right phrenic nerve carries sensory fibers
• Hepatic branch of the right vagus nerve delivers
parasympathetic innervation
• Clinical correlations
→ Wandering gallbladder
→ Gallstone/cholelithiasis
→ Biliary colic (gallbladder attack)
→ Mirrizi syndrome
→ Cholecysto-enteric fistula
→ Gallstone ileus
→ Bouveret syndrome
• Surgical considerations
→ Cholecystectomy
→ Ducts of Luschka
→ Variations in the cystic and hepatic duct
→ Accessory hepatic ducts

D. ACCESSORY HEPATIC DUCTS REVIEW QUESTIONS

• Common and are in positions of danger during cholecystectomy 1. Which costal cartilage is located anterior to the gallbladder?
• An accessory duct is a normal segmental duct that joins the a) 4th
biliary system outside the liver instead of within it b) 7th
• Since it drains a normal segment of the liver, it leaks bile if c) 9th
inadvertently cut during surgery (Skandalakis et al., 2009) d) 12th
e) NOTA
QUICK REVIEW 2. Refer to the two statements:
SUMMARY OF TERMS I. The gallbladder fossa is used as a reference point to
• Cholecystoduodenal fold determine the left and right lobes of the liver.
→ Connects the gallbladder to the first part of the duodenum II. The superior portion of the gallbladder is covered in
• Hepatoduodenal ligament peritoneum while the inferior part is not.
a) Both statements are true.
b) Both statements are false.

YL5: 08.18 Gastrointestinal System and Nutrition: Gross Anatomy of the Gallbladder 5 of 6
 c) Only statement I is true. 10. A. The fundus is the part that is palpable in cases where the
d) Only statement II is true. gallbladder can be palpated.
3. A 32 year-old male patient suffered from a stab wound in the right
upper quadrant of the abdomen. Upon further examination, REFERENCES
penetration of the gallbladder was also found. Which segments of REQUIRED
the liver may also be most likely injured? (1) Michele P. Rivera-Nuez. 21 January 2019. Gross Anatomy of the
a) II and III Gallbladder [Lecture slides].
b) IVb and V
c) VI and VII FREEDOM SPACE
d) II and IVa
4. Which follows the correct direction of the flow of bile through the
biliary tree?
a) Common hepatic duct → left hepatic duct → common bile
duct → pancreatic duct
b) Right hepatic duct → left hepatic duct → cystic duct →
hepatopancreatic ampulla
c) Common hepatic duct → common bile duct → pancreatic
duct → hepatopancreatic ampulla
d) Left hepatic duct → common hepatic duct → common bile
duct → hepatopancreatic ampulla
5. What structure allows easy passage of bile into the gallbladder
when the distal end of the bile duct is closed?
a) Spiral Valve
b) Sphincter of the bile duct
c) Sphincter of Oddi
d) Pyloric Sphincter
6. Which structure is NOT part of the sides that form the
cystohepatic triangle of Calot?
a) Cystic duct
b) Common hepatic artery
c) Inferior surface of the liver
d) Common hepatic duct
7. What would happen to the gallbladder if the hepatic branch of the
right vagus nerve is damaged?
a) Bile would flow uncontrollably through the cystic duct.
b) The sphincter of Oddi will stay relaxed.
c) Sympathetic stimulation can no longer occur.
d) The gallbladder will lose the ability to contract.
8. A 44 year-old woman is about to undergo surgery to remove a
gallstone that has obstructed her biliary tree. Which part of the
tree is most likely blocked?
a) Distal end of the hepatopancreatic ampulla
b) Proximal end of the hepatopancreatic ampulla
c) Distal end of the cystic duct
d) Proximal end of the cystic duct
9. During a routine cholecystectomy, the surgeon accidentally
damaged a structure causing bile to leak into the abdominal
cavity. Which structure was most likely damaged?
a) Spiral valve
b) Sphincter of Oddi
c) Ducts of Luschka
d) Hartmann’s pouch
e) Cholecystoduodenal duct
10. During a GI physical examination, a YL5 student was able to
palpate an organ along the right costal margin in the mid
clavicular line and noted that it was the gallbladder. Which part of
the gallbladder was most likely palpated?
a) Fundus
b) Body
c) Neck
d) Head

Answers
1. C. (Page 2, IV. Relations)
2. C. Statement II is false. The inferior portion is covered in
peritoneum.
3. B. The gallbladder is situated between segments IVb and V
of the liver. Since the stab injury reached the gallbladder,
then either of these segments was most likely perforated.
4. D. (Page 2, V. Biliary Tree)
5. A. (Page 2, V-A. Cystic Duct)
6. B. (Page 3, VI-A. Arterial Blood Supply)
7. D. The function of the gallbladder is controlled through
parasympathetic stimulation, which is carried by the hepatic
branch of the right vagus nerve. If this nerve is damaged, the
gallbladder will no longer be able to contract.
8. A. Obstructions in the biliary tree due to cholelithiasis are
most common in the distal end of the hepatopancreatic
ampulla as this area is the narrowest in the tree.
9. C. Injuries to these ducts during cholecystectomy is a
frequent cause of bile leaks.

YL5: 08.18 Gastrointestinal System and Nutrition: Gross Anatomy of the Gallbladder 6 of 6