BASIC SCIENCE

Anatomy of the gallbladder

and bile ducts

hepatic duct to form the common bile duct (Figure 1). The mucous lining of the cystic duct is often raised into a spiral fold
called the spiral valve of Heister (see Figure 2). The fold consists
of a variable number of turns and is continuous with a similar
mucosal fold in the neck of the gallbladder.
The common bile duct is 7.5e11 cm in length with an internal
diameter of 6e8 mm under normal physiological pressure.
Commencing about 2.5 cm superior to the first part of the duodenum, the common bile duct descends to lie successively
behind and then below, the first part of the duodenum before
coursing obliquely through the medial wall of the second part of
the duodenum to open into the lumen of the latter. Given this
fairly constant relationship of the common bile duct to the first
part of the duodenum, the common bile duct may, for descriptive
purposes, be divided into the following four segments: (Figure 1)
i) supraduodenal (above the first part of duodenum)
ii) retroduodenal (posterior to the first part of duodenum)
iii) infraduodenal (below the first part of duodenum and
behind the head of the pancreas)
iv) intramural (within the wall of the 2nd part of duodenum).
The retroduodenal segment, which is 2e3 cm in length, deviates laterally from the hepatic artery and portal vein to
continue as the infraduodenal segment.
The infraduodenal part of the common bile duct lies in a
groove on the posterior surface of the head of the pancreas. On
occasion this segment of the common bile duct may be
embedded in the head of the pancreas. Usually, the termination
of the common bile duct joins the termination of the main
pancreatic duct (the duct of Wirsung) to form a common vestibule, the hepatopancreatic ampulla (ampulla of Vater). The
ampulla itself opens at the summit of the major duodenal papilla,
a small inward mucosal projection from the posteromedial wall
of the second part of the duodenum, typically 10 cm distal to the
pyloroduodenal junction in the adult. The ampulla as well as the
intramural segments of the common bile duct and main
pancreatic duct are each surrounded by sphincteric smooth
muscle. The ampullary sphincter is better known as the sphincter
of Oddi. The smooth muscle constituting these sphincters is
anatomically distinct and functionally independent of the circular
and longitudinal smooth muscle in the wall of the duodenum.
The natural tonus in the smooth muscle of the sphincters causes
them to remain closed. However, gastric contents, upon entering
the duodenum, cause the duodenal mucosa to secrete cholecystokinin, a peptide hormone. This hormone causes contraction of
the gallbladder and simultaneous relaxation of the pancreatic,
biliary and ampullary sphincters permitting bile and pancreatic
secretions to enter the duodenum.
The ampulla of Vater is, almost invariably, depicted in textbooks as a distinct sac-like structure. However, inspection of a
normal retrograde cholangio-pancreatogram shows that, in the
majority of individuals, the junction forms a simple tube without
any obvious sac-like appearance. Sometimes, the common bile
duct and the main pancreatic duct open separately into the second part of the duodenum.
The common hepatic duct and the supraduodenal part of the
common bile duct lie within the free edge (right edge) of the
lesser omentum (Figure 3), where the two leaves of the lesser
omentum become continuous with each other. This free edge,
where the two leaves of the lesser omentum become continuous

Vishy Mahadevan

Abstract
The biliary system or biliary tract denotes the elaborate system of coalescing channels which serves to transport bile from the liver to the second part of the duodenum. Bile is an alkaline liquid produced by the
hepatocytes, partly as a secretion and partly as an excretory product.
The biliary system commences within the substance of the liver as narrow
intercellular channels between adjacent hepatocytes. These channels,
termed canaliculi, coalesce with their neighbours to form larger channels
termed ductules. The latter join other ductules to form ducts. These unite
with other ducts to form larger ducts which eventually emerge from the
liver as the right and left hepatic ducts. The latter unite to form the common hepatic duct which, after being joined by the cystic duct, continues
as the common bile duct and empties into the second part of the duodenum. For descriptive purposes the biliary tract is subdivided into two
parts: intrahepatic and extrahepatic. The former is situated within the
substance of the liver while the latter lies entirely outside the hepatic substance. This article is confined to a description of the clinical and surgical
anatomy of the extrahepatic biliary tract. The extrahepatic biliary tract
comprises the right and left hepatic ducts, common hepatic duct, gallbladder and cystic duct and the common bile duct. Diseases of the extrahepatic biliary tract account for a considerable volume of abdominal
surgical practice. These include metabolic, inflammatory, neoplastic and
congenital conditions. A detailed knowledge of the anatomy of the gallbladder and bile ducts and an awareness of the anatomical variations
to which these structures are subject are essential to the conduct of
safe and effective surgery involving the biliary tract, besides being of
crucial importance to the accurate interpretation of radiological and ultrasound images of the extrahepatic biliary tract.

Keywords Ampulla of Vater; anatomical variations; bile ducts; blood

supply; Calots triangle; gallbladder; sphincter of Oddi

The biliary ducts (Figure 1)

The right and left hepatic ducts emerge from the liver and unite at
the right end of the porta hepatis (the transverse fissure on the
visceral surface of the liver, also known as the hilum of the liver)
to form the common hepatic duct. The common hepatic duct is,
on average, 4 cm in length and approximately 4 mm wide. It is
joined on its right side, at an acute angle, by the cystic duct. The
latter connects the gallbladder to the common hepatic duct.
(Figure 1)
The cystic duct is 3e4 cm in length and approximately 3 mm
wide. From its commencement at the neck of the gallbladder, it
passes posteriorly, inferiorly and medially to join the common

Vishy Mahadevan MBBS PhD FRCS (Ed & Eng) is the Barbers Company
Professor of Anatomy at the Royal College of Surgeons of England,
London, UK. Conflicts of interest: none.

SURGERY --:-

2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Mahadevan V, Anatomy of the gallbladder and bile ducts, Surgery (2014), http://dx.doi.org/10.1016/
j.mpsur.2014.10.003

BASIC SCIENCE

Schematic illustration of intrahepatic and extrahepatic biliary tract

Right medial (anterior)
hepatic duct
VIII
Right lateral
(posterior) duct

V
VII
I

Right main hepatic

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

The level of the porta hepatis is indicated by the dashed line.

Figure 1

Schematic view of interior of gallbladder and extrahepatic biliary tract

Neck
Body
Cystic duct
Fundus
Right and left
hepatic ducts

Common
hepatic duct

Spiral
valve

Common
bile duct

Figure 2

SURGERY --:-

2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Mahadevan V, Anatomy of the gallbladder and bile ducts, Surgery (2014), http://dx.doi.org/10.1016/
j.mpsur.2014.10.003

BASIC SCIENCE

Illustration showing Calots triangle, epiploic foramen and structures in the hepatoduodenal
ligament
Ligamentum teres in falciform ligament
Liver

Gallbladder

Left branch
of
Portal vein

Cystic artery
Cystic duct

Lesser omentum

Common hepatic duct

Hepatic artery

Bile duct

Inferior vena cava

Epiploic foramen

Anastomosis between
right and left
gastric arteries

Duodenum
Right kidney

Stomach

Right gastroepiploic
artery
a
Bile duct
Hepatic artery
Portal vein
Epiploic foramen
Inferior vena cava
b
Epiploic foramen and its boundaries seen in transverse section.

Figure 3

with each other, is more commonly known in the surgical literature as the hepatoduodenal ligament. The arrangement of
structures within the free edge of the lesser omentum is as follows. The common hepatic duct and its distal continuation the
common bile duct lie immediately to the right of the hepatic
artery. Lying immediately posterior to the hepatic artery and
biliary tract and parallel to both is the portal vein. Accompanying
these structures within the free edge of the lesser omentum are
lymphatics, lymph nodes and autonomic nerve fibres. Superiorly
the two leaves of the lesser omentum are attached to the margins
of the porta hepatis (Figure 3). The free edge of the lesser
omentum with its contents forms the anterior boundary of the
epiploic foramen (of Winslow), while the peritoneum lying in
front of the inferior vena cava forms the posterior boundary. The
epiploic foramen is a natural intraperitoneal opening between the
general peritoneal cavity (greater sac) and the lesser sac
(Figure 3b). Haemorrhage during open surgery of the gallbladder
or liver may be controlled by temporarily occluding the portal
vein and hepatic artery by compressing the free edge of the lesser

SURGERY --:-

omentum with a vascular clamp, or by passing a finger through

the epiploic foramen and compressing the artery and portal vein
between the finger and the thumb (Pringles manoeuvre).
Running within the free edge of the lesser omentum, the hepatic artery and the portal vein reach the porta hepatis, and each
divides into a right branch and left branch for the corresponding
hemilivers. The right and left hepatic ducts emerge from the
porta hepatis and unite to form the common hepatic duct.

The gallbladder (Figures 1e4)

The gallbladder is a pear-shaped, thin-walled, distensible sac
with a capacity of approx. 50 mL. The gallbladder lies on the
visceral surface of the liver in a narrow fossa, termed the cystic
fossa, which runs from the anterior margin of the inferior surface
of the liver, posterosuperiorly towards the inferior vena cava
(Figure 4). The cystic fossa lies immediately to the right of the
quadrate lobe of the liver. The peritoneum that covers the
visceral surface of the liver is continued over the inferior surface
of the gallbladder. The superior surface of the gallbladder,

2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Mahadevan V, Anatomy of the gallbladder and bile ducts, Surgery (2014), http://dx.doi.org/10.1016/
j.mpsur.2014.10.003

BASIC SCIENCE

Relationship of gallbladder to visceral surface of liver

Gallbladder

Quadrate lobe Falciform ligament Ligamentum teres

Omental
tuberosity

Colic area

Gastric area

Right lobe

Left lobe

Ligamentum
venosum
Hepatic artery

Renal
impression

Caudate process

Oesophageal impression

Caudate lobe
Bare area Inferior vena cava Bile duct and portal vein

Figure 4

Imaging of the extrahepatic biliary tract

however, is directly related to the liver without any intervening

peritoneum. Occasionally the gallbladder may be completely
enveloped in visceral peritoneum and suspended from the liver
by a mesentery. Such an anomaly may predispose the gallbladder
to torsion. The gallbladder is divided for descriptive purposes
into a fundus, body and neck, the latter opening into the cystic
duct (Figure 2). The fundus is the rounded end which projects
beyond the anterior margin of the visceral surface of the liver
and lies behind the tip of the 9th costal cartilage. The body and
neck are directed superomedially towards the porta hepatis
(Figure 4).
Inferiorly, the gallbladder relates to the first and second parts
of the duodenum and to the hepatic flexure of the colon. An
inflamed gallbladder may adhere to any of these structures, and
on occasion may erode their walls. A large gallstone may thus
drop into the lumen of the duodenum and may become impacted
in the distal small intestine causing intestinal obstruction (i.e.
gallstone ileus).
Bile as it leaves the liver is 97% H2O, 1% pigment and 1e2%
bile salts. The principal function of the gallbladder is to act as a
reservoir for bile. It also concentrates bile by a factor of nearly 10
by a process of active reabsorption of H2O, NaCl and HCO3, and
makes the bile viscous by secretion of mucus.

Oral cholecystography and intravenous cholangiography are now

practically obsolete in the developed world. The imaging methods
that are currently used to delineate the biliary tract and which
provide the greatest amount of anatomical information are ultrasonography, ERCP (endoscopic retrograde cholangiopancreatography), PTC (percutaneous transhepatic cholangiography) and
MRCP (magnetic resonance cholangiopancreatography). The last
named is non-invasive, does not involve the use of contrast media
and yields a most impressive degree of anatomical detail.

Blood supply and venous drainage of the extrahepatic biliary

tract
The gallbladder derives its blood supply from the cystic artery.
Commonly, this vessel arises from the right hepatic artery within
the hepatoduodenal ligament, and usually passes behind the
common hepatic duct to reach the neck of the gallbladder and
then to branch over the surface of the body of the gallbladder
(Figure 3). However, variations in the origin of the cystic artery
are frequent. The cystic artery may arise from the left hepatic
artery or from the trunk of the hepatic artery, or even from the
gastroduodenal artery. Furthermore the cystic artery may pass in
front of, instead of behind, the bile ducts, to reach the gallbladder. Nevertheless, the cystic artery, whatever its origin, is
almost invariably situated within Calots triangle (or cystohepatic
trigone). This triangle is situated very deeply. It is bounded superiorly by the visceral surface of the liver adjacent to the porta
hepatis; medially by the common hepatic duct and inferolaterally
by the cystic duct and neck of the gallbladder (Figure 3) In
addition, the gallbladder receives numerous arterial twigs from

Histological structure
The gallbladder and the sphincter of Oddi contain involuntary
muscle, but there are only scattered muscle fibres in the remaining
parts of the biliary tract. The mucosa of the gallbladder and biliary
tract has a lining columnar epithelium. The gallbladder mucosa
features numerous mucus-secreting goblet cells.

SURGERY --:-

2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Mahadevan V, Anatomy of the gallbladder and bile ducts, Surgery (2014), http://dx.doi.org/10.1016/
j.mpsur.2014.10.003

BASIC SCIENCE

Embryology and developmental anomalies

the right hepatic artery via the gallbladder bed in the liver. These
are sometimes seen at laparoscopy. The blood supply to the
common hepatic duct and common bile duct is from the cystic
and hepatic arteries, and from the gastroduodenal and superior
pancreaticoduodenal arteries. These vessels contribute to longitudinal anastomotic channels which lie on the wall of the bile
ducts along the lateral and medial borders.
Venous drainage of the gallbladder is by numerous veins
which accompany the arterial twigs to the gallbladder in its bed,
and which are visible at laparoscopy, provided the gallbladder is
not grossly inflamed or thickened. They drain into the radicles of
the right portal vein in the liver bed. Rarely, one or more cystic
veins are present and drain from the neck of the gallbladder to
the right branch of the portal vein.

The gallbladder and the bile ducts are subject to numerous variations, and these are best understood by considering their
embryological development. As early as the third week of
development, an endodermal outgrowth, termed the hepatic
diverticulum, develops from the ventral wall of the very distal
end of the embryonic foregut. This grows in a ventrocranial direction to meet the septum transversum within which it proliferates to give rise to cords of liver cells. The lower part of the
hepatic diverticulum narrows to form the bile duct. A ventral
outgrowth from the bile duct primordium differentiates into the
gallbladder and cystic duct. Variations in anatomy include: (i) a
long cystic duct which joins the common hepatic duct behind the
duodenum; (ii) a short, or even absent, cystic duct; (iii) the cystic
duct opening into the left side of the common hepatic duct; and
(iv) the presence of accessory hepatic ducts.
Developmental anomalies of the gallbladder include agenesis
of the gallbladder, bilobed gallbladder and multiple
gallbladders.
A

Lymphatic drainage of the extrahepatic biliary tract

Lymphatics from the gallbladder drain into the hilar nodes (i.e.
lymph nodes in the porta hepatis) and to the cystic lymph node
(of Lund) that is situated in Calots triangle. Lymph from the
common hepatic duct and upper part of common bile duct drains
into the hilar nodes while lymph from the lower half of the
common bile duct travels inferiorly to drain into the superior
pancreaticoduodenal and retroduodenal lymph nodes. Eventually all these nodes drain into the coeliac group of lymph nodes
which lie around the origin of the coeliac artery (coeliac trunk).

FURTHER READING
Ellis H, Mahadevan V. Clinical anatomy. 13th edn. WILEY Blackwell, 2013;
106e9.
Keplinger KM, Bloomston M. Anatomy and embryology of the biliary tract
in Surgical Clinics of North America April 2014; 203e17. 94: 203e17.
Langmans medical embryology. 12th edn. TW Sadler Wolters Kluwer/Lippincott Williams & Wilkins, 2012; 217e21.
Moore KL, Dalley AF, Agur AMR. Clinically oriented anatomy. 7th edn.
Wolters Kluwer/Lippincott Williams & Wilkins, 2014; 277e80.
Vakili K, Pomfret EA. Biliary anatomy and embryology in Surgical Clinics of
North America Dec. 2008; 1159e73. 88: 1159e73.
Williams NS, Bulstrode CJK, OConnell Hodder Arnold PR, eds. Bailey and
Loves short practice of surgery. 25th edn 2008; 1111e9.

Innervation of the extrahepatic biliary tract

The efferent, motor innervation of the gallbladder and bile ducts is
by sympathetic and parasympathetic fibres. The latter are derived
from the anterior and posterior vagal trunks and accompany the
hepatic and cystic arteries to reach the biliary tract. The sympathetic fibres run in the splanchnic nerves, pass through the coeliac
ganglion and then reach the biliary tract. Visceral afferent fibres
for pain run with the sympathetic efferents.

SURGERY --:-

2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Mahadevan V, Anatomy of the gallbladder and bile ducts, Surgery (2014), http://dx.doi.org/10.1016/
j.mpsur.2014.10.003