REVIEW
Surgical anatomy
of laparoscopic
cholecystectomy
S Sood
WEG Thomas
Vishy Mahadevan
Abstract
Laparoscopic cholecystectomy is one of the most common general surgi-
cal operations performed worldwide. The first open cholecystectomy was
performed by Carl Langenbuch of Berlin in 1882 and the first laparoscopic
cholecystectomy was performed by Mu €he in 1986.
Anatomy
The gall bladder (GB) is a pear shaped reservoir, 5e7 cm long,
and can hold approximately 30e50 ml of bile. It lies between the
quadrate and the anatomical right lobe of the liver in the
depression in its right inferior surface known as the gall bladder
fossa. The GB consists of a distal bulbous fundus (which usually
projects beyond the inferior border of the liver in the region of
the right ninth costal cartilage), the main body of the organ, and
then the neck which terminates in the cystic duct (Figure 1). The
cystic duct is 2e4 cm in length and contains mucosal folds
known as the spiral valve of Heister, which allows easy entry of
bile into the GB but provides a degree of resistance to its outflow.
Pathological changes in the GB associated with cholelithiasis
may result in a stone impacted in the neck causing dilatation at
the junction of the neck and the cystic duct, and this dilated area
is known as Hartmann’s pouch.
The extra-hepatic bile ducts lie within the free edge of the
lesser omentum in the hepatoduodenal ligament. Normally the
right hepatic duct and the left hepatic duct join to form the
common hepatic duct (CHD). The left hepatic duct tends to run a
more transverse course than the right hepatic duct and therefore
is more surgically accessible. The length of the CHD is variable
because it is determined by the point where cystic duct joins it to
form the common bile duct (CBD). Typically the common hepatic
duct measures 2.5e3.5 cm long while the CBD is 7e10 cm long
and up to 6 mm wide. The CBD passes behind the first part of the
duodenum, in the groove in the back of the head of pancreas and
then enters the medial duodenal wall, where it is joined by the
S Sood FRCS Formerly Surgical Registrar at the Royal Hallamshire
Hospital, Sheffiled, UK.
WEG Thomas MS FRCS FSACS(Hon) Consultant Surgeon, Honorary Senior
Lecturer, Sheffield University, Member of Council and past Vice Presi-
dent of the Royal College of Surgeons of England, UK.
Vishy Mahadevan Professor, Department of Anatomy, Royal College of
Surgeons of England, Lincoln’s Inn Fields, London, UK.
SURGERY 32:S1
Descargado para Joshua Macias (joshuamacias605@gmail.com) en Pontifical Catholic University of Ecuador de ClinicalKey.es por Elsevier en abril 29,
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main pancreatic duct of Wirsung within the ampulla of Vater. It
is endoscopically and surgically recognized by the papilla which
is situated on the medial wall of the second part of the duodenum
approximately 10 cm distal to the pylorus. At its distall end it is
enveloped by the smooth muscle of the sphincter of Oddi, which
controls the flow of bile and pancreatic secretions into the
duodenum.
The main blood supply to the GB is provided by the cystic
artery which commonly arises from the right branch of the he-
patic artery, posterior to the common hepatic duct, although
anatomical variations are very common. The cystic artery runs
above and behind the cystic duct to reach the neck of the GB
where it divides into an anterior and posterior branch. In addi-
tion to the cystic artery the GB receives a variable blood supply
directly from the liver through its bed.
The CBD receives its blood supply from the retroduodenal
common hepatic artery and the right hepatic artery. Branches from
these two main vessels form a plexus on the duct that is supported
by two axial vessels, the 3 o’clock and the 9 o’clock arteries, named
for their positions in reference to cross section of the duct. The
venous drainage of the GB and the extrahepatic biliary ducts is
directly into the portal vein. The cystic lymph node of Lund lies
adjacent to the cystic artery where it meets the GB wall, and is
therefore an important landmark during cholecystectomy. Lymph
from the GB and the proximal bile ducts passes through the cystic
node and into other infrahepatic nodes related to the free edge of
the lesser omentum. At the lower end of the bile duct lymph passes
into the pancreatic and the paraduodenal nodes.
Calot’s triangle is formed by the CHD to the left, the cystic
duct below and the inferior surface of the liver above. The con-
tents of the triangle are the cystic artery and the cystic lymph
node of Lund. This triangle is a crucial landmark during chole-
cystectomy, and must be displayed during every cholecystec-
tomy before any ductal structure is divided.
Variations in anatomy and its significance
A knowledge of the variations in the anatomy of the GB, the bile
ducts and the arteries that supply them, is crucial to the surgeon,
because failure to recognize them can cause iatrogenic injury to
the biliary tract. The significant variations in the ductal anatomy
are shown in Figure 2. Some of the more common variations
include:
 A long cystic duct, running parallel to the CHD, with low
insertion into CBD. The duct may pass behind the common
hepatic duct to enter its posterior wall or even its left
lateral aspect.
 A high insertion of the cystic duct into the region of the
CHD bifurcation or into the right hepatic duct.
 In chronic cholecystitis, the GB may be small and
shrunken, and the cystic duct may be extremely short. In
this situation, the CBD may easily be mistaken for the
cystic duct, and therefore a fundus first approach may be
advisable.
 An accessory duct from the liver may enter the cystic duct
or the common hepatic duct. Actually this is not an
accessory duct but an anomalous entry of either the right
anterior or the right posterior segmental duct from the
liver. If this variation is not recognized, it will result in
division of the duct and a biliary fistula.
e6 Ó 2013 Published by Elsevier Ltd.
 REVIEW

Right medial (anterior)
hepatic duct
VIII
Right lateral
V (posterior) duct
VII Right main hepatic
I duct
I II
VI
III
IV Left main hepatic duct
Common hepatic duct
Cystic duct
Supraduodenal
common bile duct
Retroduodenal
bile duct
Retropancreatic
bile duct
Figure 1 Overall arrangement of the intrahepatic and extrahepatic biliary
tree. The segmental ducts often branch just before, or are multiple, as
they enter the main ducts, but for clarity are shown here as single ducts.
Note that segment I usually has drainage from both right and left hepatic
ducts. The level of the liver parenchyma at the porta hepatis is shown by
the dashed brown line. (For interpretation of the references to colour in
this figure legend, the reader is referred to the web version of this article.)
Intraoperative cholangiography, injecting radio-opaque
contrast into the biliary tract and then using an image intensi-
fier to view the duct system, maybe useful in confirming such
anatomical anomalies, but should not be relied on to primarily
identify them. Significant damage to the duct system can occur
before an operative cholangiogram is performed, and there is no
substitute for a clear display of the anatomy before any ductal
structure is ligated or divided. Indeed many surgeons do not
routinely undertake operative cholangiography.
Variations in the anatomy of the hepatic and the cystic arteries
that are of surgical significance are shown in Figure 3. In 20 % of
the individuals the cystic artery arises from the right hepatic
artery that runs anterior to the common hepatic duct, and in 7 %
of individuals the right hepatic artery forms a loop or a “cater-
pillar hump” with the cystic artery originating from the apex. In
this latter case, the right hepatic artery may be mistaken for the
cystic artery during cholecystectomy.
Anomalies of GB
Very rarely the GB may be absent, which may be associated with
other congenital anomalies such as biliary atresia, cardio-
vascular or other gastro-intestinal malformations. It may be
completely buried within the liver parenchyma (intra-hepatic) or
completely covered with peritoneum on all sides forming a
mesentery called a floating GB, which can predispose to torsion.
It may also be found on the left side of the falciform ligament, on
the under surface of the left lobe in association with situs
inversus. Double or triple GB have been reported which may be
completely separate or divided by a septum. These may or may
not share a common cystic duct.
Laparoscopic cholecystectomy
Cholecystectomy is indicated for symptomatic cholelithiasis or
rarely for asymptomatic cholelithiasis in order to prevent compli-
cations. Liver function tests and an ultrasound scan of the upper
abdomen are the two most important investigations. The latter also
can provide information as to the diameter of the CBD and the
presence of any ductal stones. Sometimes further investigations
such as magnetic resonance cholangio-pancreaticography (MRCP)
or endoscopic retrograde cholangio-pancreaticography (ERCP)
may be required if ductal stones are suspected or a poor view is
obtained of the distal duct due to intestinal gas. Currently chole-
cystectomy is mostly undertaken by laparoscopic means.
The advantages of laparoscopic over open cholecystectomy are
 Earlier return of bowel function
 Less post-operative pain
 Improved cosmesis
 Shorter length of hospital stay
 Earlier return to full activity
The patient is placed in the supine position with the surgeon and
the assistant on the left side of the patient and the monitor on the
right side of the patient. After appropriate preparation and draping,
the pneumoperitoneum is established with carbon dioxide with the
help of a Veress needle (closed technique) or by the open Hassan
technique (which is deemed much safer and the preferred option)
by means of a small incision just underneath the umbilicus. The
whole of the peritoneal cavity is inspected and the gall bladder

Cystic duct variants

A1 Low entry A2 Medial side entry A3 Common drainage A4 Accessory cystic

with right lateral duct (segment V)
sectoral duct

Figure 2 Variations in the anatomy of the cystic and interhepatic bile ducts. The cystic duct variations are labelled A1eA3 and the letters BeF are used for
the variants of the intrahepatic ducts to ensure consistency with the Blumgart nomenclature.

SURGERY 32:S1 e7 Ó 2013 Published by Elsevier Ltd.

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 REVIEW

a Common hepatic artery b Low origin common hepatic artery c Gastroduodenal artery d Superior pancreaticoduodenal,
coeliac or right gastric arteries

e Left hepatic artery f Accessory deep artery g Multiple non-dominant arteries

Figure 3 Variant anatomy of the cystic artery origin and distribution.

identified. Three more ports are then inserted under direct vision e
one 10e12 mm in the midline below the xiphisternum, one 5 mm
in the right sub costal area in the mid-clavicular line, and a second 5
mm on the right anterior axillary line between 12th rib and the iliac
crest. The GB fundus is held by a grasper through the lateral port,
and is retracted up and laterally, thus elevating the liver. With the
help of another grasping forceps in the medial 5 mm port, the
infundibulum or the neck of the GB is held and retracted down and
lateral to display Calot’s triangle clearly. It is crucial to clearly
identify Calot’s triangle and its contents before any structure is
clipped or divided and this is achieved using the dissecting forceps
through the epigastric port. In cases in which the anatomy is un-
clear, an intraoperative cholangiogram may be performed to
confirm the ductal configuration, but if any doubt still persists,
then conversion to an open procedure for better access and
anatomical clarification may be necessary. The cystic artery and
the cystic duct should be dissected and clearly identified and then
doubly clipped proximally and distally, and then divided between
the clips. The gall bladder can then be safely dissected from its
fossa on the under surface of the liver with the help of a diathermy
hook. Care must be taken not to puncture the gall bladder in order
to avoid any biliary spillage. However very occasionally in very
thickened and diseased gall bladders it is acceptable to leave the
posterior wall of the gall bladder in situ in order to prevent CBD
damage. Having achieved haemostasis, the specimen can be
delivered, usually through the umbilical port, using a BERT (bag
for endoscopic retrieval of tissue) if necessary. The carbon dioxide
is then let out and the rectus sheath of the 10 mm port sites sutured
with an unabsorbable suture material and the skin of all the ports
closed with fine subcuticular absorbable suture material. The pa-
tient is usually discharged home after a one night stay, although an
uncomplicated procedure can be undertaken as a day case. A

SURGERY 32:S1 e8 Ó 2013 Published by Elsevier Ltd.

Descargado para Joshua Macias (joshuamacias605@gmail.com) en Pontifical Catholic University of Ecuador de ClinicalKey.es por Elsevier en abril 29,
2023. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.