Gall Bladder&Bile

Ducts Surgery
1
Emad Geddoa
FICS, MD, MRCS
Laparoscopic General & GIT Surgeon
October 2018
 Learning Objectives

• To understand the anatomy and physiology

of the gall bladder and bile ducts.
• To be familiar with the pathophysiology and
management of gallstones
 Surgical Anatomy & Physiology

• The gall bladder lies on the underside of the liver at

the junction of the right and left functional lobes of
the liver.

• The relationship of the gall bladder to the liver

varies between being embedded within the liver
substance to being suspended by a mesentery.

• It is a pear-shaped structure, 7.5–12 cm long, with

a normal capacity of about 30-50 ml.
• The anatomical divisions are fundus, body and neck that
terminates in to a duct called Cystic duct.

• At the junction of the neck of the gallbladder and the cystic duct,
there is an out-pouching of the gallbladder wall forming a
mucosal fold known as Hartmann's pouch, where gallstones
commonly get stuck.

• The muscle fiberes in the wall of the gall bladder are arranged in
a criss-cross manner, being particularly well developed in its
neck.

• The mucous membrane contains indentations of the mucosa that

sink into the muscle coat; these are the crypts of Luschka.
• The cystic duct is about 3 cm in length, with 1-3 mm lumen

• The mucosa of the cystic duct is arranged in spiral folds

known as the ‘valves of Heister’ and the wall is surrounded by
a sphincteric structure called the ‘sphincter of Lütkens'.

• The cystic duct joins the supraduodenal segment of the

common hepatic duct in 80 per cent of cases; however, the
anatomy may vary and the junction may be much lower in the
retroduodenal or even retropancreatic part of the bile duct.

• Occasionally, the cystic duct may join the right hepatic duct .
• The common hepatic duct is usually less than 2.5 cm long and is
formed by the union of the right and left hepatic ducts.

• The common bile duct is about 7.5 cm long and up to 7 mm in

diameter and formed by the junction of the cystic and common
hepatic ducts. It is divided into four parts:

• •Supraduodenal portion about 2.5 cm long, running in the free

edge of the lesser omentum.
• Retroduodenal portion.
• Infraduodenal portion lies in a groove on the posterior surface of
the pancreas.
• Intraduodenal portion passes obliquely through the wall of the
second part of the duodenum, where it is surrounded by the
sphincter of Oddi, and terminates by opening on the summit of the
ampulla of Vater.
• The cystic artery, a branch of the right hepatic
artery, usually arises behind the common hepatic
duct .

• Occasionally, an accessory cystic artery arises from

the gastroduodenal artery.

• In 15 per cent of cases, the right hepatic artery

and/or the cystic artery cross in front of the
common hepatic duct and the cystic duct.
 Calot’s Triangle

• Calot's triangle or the hepatobiliary triangle is the

space bordered by the cystic duct inferiorly, the
common hepatic duct medially and the inferior
border of the liver superiorly.

• This was described in 1891 by Jean-François Calot.

It is an important surgical landmark and should be
identified by surgeons performing a
cholecystectomy to avoid damage to the
extrahepatic biliary system.

• Contents of calot’s triangle are: cystic artery,

accessory right hepatic artery,lunds lymph nodes
(mascagni LN), anomalous bile duct)
Common abnormalities:
• A: Normal. B: Tortuous common hepatic artery. C: Tortuous right hepatic artery.
 Lymphatic Drainage
• The lymphatic vessels of the gall bladder
(subserosal and submucosal) drain into the cystic
lymph node of Lund (the sentinel lymph node).

• Efferent vessels from this lymph node go to the

hilum of the liver, and to the celiac lymph nodes.

• The subserosal lymphatic vessels of the gall bladder

also connect with the subcapsular lymph channels
of the liver, and this accounts for the frequent
spread of carcinoma of the gall bladder to the liver.
 Surgical Physiology

• Bile is produced by the liver and stored in the gall bladder from
which it is released into the duodenum.

• As it leaves the liver, it is composed of 97 per cent water, bile

salts (cholic and chenodeoxycholic acids, deoxycholic and
lithocholic acids), phospholipids, cholesterol and billirubin.

• The liver excretes bile at a rate estimated to be approximately 30-

40 mL/hour (750-950 ml/24h)

• About 95 per cent of bile salts are reabsorbed in the terminal

ileum (enterohepatic circulation)
 Functions of the Gall Bladder

1. Reservoir for bile. During fasting, resistance to flow through the sphincter
of Oddi is high, and bile excreted by the liver is diverted to the gall bladder.
After feeding, the resistance to flow through the sphincter is reduced, the gall
bladder contracts and the bile enters the duodenum.
These motor responses of the biliary tract are in part effected by the hormone
cholecystokinin.
2. Concentration of bile by active absorption of water,
sodium chloride and bicarbonate by the mucous
membrane of the gall bladder.
The hepatic bile which enters the gall bladder becomes
concentrated 5–10 times, with a corresponding
increase in the proportion of bile salts, bile
pigments, cholesterol and calcium.
3. Secretion of mucus – approximately 20-30 ml is
produced per day.
With complete obstruction of the cystic duct in an
otherwise healthy gall bladder, a mucocoele may
develop as a result of ongoing mucus secretion by
the gall bladder mucosa.
 Compositions of bile

1.Bile pigment: cholestrol, drug and steroid excretion

2. Bile salts:Excretion of conjugated bilirubin into small
bowel
3. Cholestrol: Emulsification of fat for digestion
4.Bicarbonate:Absorption of fat soluble vitamins(DEAK)
5.Lecithine : Micelle formation
6.Phospholipid: Gastric Acid neutralisation
7.Water
Radiological Investigations of Biliary Tract

• X-Ray: Calcified Gall stone (10%)

• Ultrasound Scan: Stones and biliary dilation
• CT Scan: anatomy liver, gall bladder and pancreas
cancer
• MRCP: Anatomy and stones
• ERCP: Anatomy,stones and biliary stricture
• PTC: Anatomy and biliary stricture
• EUS (Endoscopic U/S Scan): Anatomy and stones
• HIDA Scan = Hepatobiliary Iminodiacetic Acid
(cholescintigraphy
) : Function,Bile leak,biliary blockage
 Radiological Investigations of Biliary Tract

• Plain x-rays

• The skillfully taken plain x-ray of the gall bladder will show
radiopaque gallstones in 10 per cent of patients.
• Rarely, the centre of a stone may contain radiolucent gas in a
triradiate or biradiate fissure and this gives rise to
characteristic dark shapes on a radiograph – the ‘Mercedes–
Benz’ or ‘seagull’ sign.
• A plain x-ray may also show the rare cases of calcification of the gall bladder, a so-called ‘porcelain’ gall bladder.The importance of
this appearance is that it is associated with carcinoma in up to 25 per cent of cases and is an indication for cholecystectomy
• Gas in the gall bladder and gall bladder wall (Clostridium perfringens). Emergency surgery is
indicated.
HIDA Scan
EUS
Peroperative cholangiography
Peroperative cholangiography. (a) Normal common bile duct: gentle infusion of
contrast which passes without hindrance into the duodenum. (b) The common bile
duct is dilated with multiple stones. Contrast is seen to reflux into the pancreatic
duct. A sphincterotomy was performed