11

Surgical Anatomy of the Gallbladder, Liver,

and Biliary Tree
Paul E. Wise and Michael D. Holzman

Discussion of laparoscopic cholecystectomy would not be as the French segmental system for hepatic anatomy,2 in
complete without a thorough review of the anatomy of the 1950s. This system shows more consideration for the
the liver, biliary tree, and gallbladder. Much of today’s hepatic venous drainage but also applies to the portal,
hepatobiliary anatomy was described by Couinaud in biliary, and arterial anatomy.3 Instead of four hepatic divi-
the mid-1900s and further delineated by corrosion casts, sions, as in the topographical system, there are eight divi-
stereoscopic radiographs, and computerized three- sions or segments: four on the right, three on the left, and
dimensional imagery. The biliary system and hepatic vas- one corresponding to the topographical caudate lobe
culature are generally much more variable than any other (segment I). Segments II through IV constitute the left
part of the human anatomy.1 The commonly described lobe and segments V through VIII the right lobe (Fig.
biliary system and potential anomalies from the cholan- 11.1). The three main hepatic veins divide the liver into
giocytes to the lower duodenal sphincter apparatus are four sectors called portal sectors, each of which receives
the focus of this chapter. In addition, anatomic changes a portal vein pedicle (Fig. 11.2). The planes containing the
that result from pathophysiological processes requiring right, middle, and left hepatic veins are called portal scis-
cholecystectomy are also addressed. surae (right, main, and left), and the planes containing
portal pedicles are called hepatic scissurae.2

General Anatomy of the Liver American (Lobar) System

Grossly, the liver appears divided into two lobes (right The American system of hepatic classification is based on
and left) by the umbilical fissure and falciform ligament. the fact that the distribution of the major branches of the
This topographical lobar anatomy is misleading in com- veins, arteries, or bile ducts of the liver does not conform
parison to the actual functional or segmental anatomy of precisely to the topographical anatomy. The relationships
the liver. Topographically, the inferior aspect of the right between the hepatic veins and portal vein branches
lobe is bound posteriorly by the transverse fissure, with therefore determine the lobar anatomy of the liver in this
the tissue lying anterior to this called the quadrate lobe. classification system.4 The lobar anatomy of the liver is
Also posteriorly, behind the portal vein, is another dis- best demonstrated by direct injection of its blood supply
tinct region known as the caudate lobe. These four lobes with substances such as methylene blue or colored
(right, left, caudate, and quadrate) constitute the major celloidin (Fig. 11.3). A plane called the portal fissure
topographical lobar anatomy of the liver. Use of the term (Cantlie’s line) passes from the left side of the gallblad-
lobes in the topographical sense has become routine in der fossa to the left side of the inferior vena cava to divide
descriptions of the liver, but most hepatobiliary surgeons the liver into its right and left lobes. The left lobe consists
and endoscopists use either the French or American clas- of a medial segment, which lies to the right of the falci-
sification of hepatic anatomy (or both) to describe the form ligament and umbilical fissure, and a lateral
liver’s segmental anatomy. segment, which lies to the left of the falciform ligament.
The right lobe consists of an anterior and a posterior
segment. No visible surface marking delineates the lobar
French Segmental System
segmental anatomy on the right. Conventionally, most of
Couinaud most completely developed the functional the topographical caudate lobe is in the medial segment
anatomic description of the liver, which became known of the left lobe, but it extends over the plane between the

73
74 P.E. Wise and M.D. Holzman

correspond to the segments described in the French

system.

II
VIII
Definitions
III It is important to carefully define a number of terms uti-
VII
I lized in this chapter and in surgical practice. The terms
proximal and distal in the biliary system refer to the direc-
tion of biliary flow. Therefore, the proximal end would be
within the parenchyma of the liver, the distal end being
IV
at the ampullary apparatus. As already described, the
V term lobe or lobar refers to the American system of
anatomy, with the division of right and left lobes being
VI
the gallbladder fossa (Cantlie’s line). Whenever the term
lobe is used to describe topographical anatomy, it is used
in conjunction with another term (e.g., caudate lobe). The
Right Left term segment or segmental refers to the French segmen-
tal system. For clarity, the American meaning of segment
Figure 11.1. The French segmental system of hepatic anatomy is not used within this chapter unless specified.
described by Couinaud and determined by portal venous flow The term common bile duct refers to the portion of the
and hepatic venous drainage. major biliary system only from the junction of the cystic
duct to the duodenal communication. The portion of the
biliary system above the junction of the cystic duct up to
gallbladder and the inferior vena cava into the right lobe.5 the hepatic duct confluence is the common hepatic duct.
The conceptual division of the liver into lobes and seg- By definition, the term common duct includes the actual
ments forms the basis for the classic types of major junctional area with the cystic duct but the common
hepatic resections (left or right lobectomy, left lateral hepatic duct term does not. The confluence refers to the
segmentectomy, and right trisegmentectomy) (Fig. 11.4). most predominant biliary junction of the right and left
The lobes may be further divided into subsegments that lobes of the liver; this may or may not be the last junc-
tion of the right and left lobe. For example, an accessory
duct from segment VI may join the common hepatic duct
or cystic duct considerably below the confluence. It is also

Right Left
scissura scissura
I Right lobe Left lobe

VII VIII
Anterior
Medial
IV III II Lateral
VI V

Left
Right
Posterior

Main Cantille’s
scissura line

Figure 11.2. Another view of how the French segmental Figure 11.3. The American (lobar) system of hepatic anatomy
system divides the liver. Each portal sector receives one of four is also determined by the relationships of the portal and hepatic
portal pedicles. The planes between these sectors are called the veins, but this system does not routinely subsegment the liver
portal scissurae and contain the three hepatic veins. as much as the French system.
11. Surgical Anatomy of the Gallbladder, Liver, and Biliary Tree 75

Figure 11.4. Classic liver resections based (trisegmentectomy) Left lateral

on the American system of hepatic anatomy. Right extended lobectomy segmentectomy
A. Right lobectomy. B. Left lobectomy.
C. Trisegmentectomy or right extended Right hepatic lobectomy Left hepatic lobectomy
lobectomy. D. Left lateral segmentectomy.

Anterior
superior Middle
superior Lateral superior
Posterior
superior
Lateral inferior

Posterior Anterior
inferior inferior

Medial
inferior

possible that there are more than two ducts which define fibers that constricts the biliary passage and may close the
the confluence. A segmental duct drains the parenchyma natural orifice.
of a French segment, that is, segments I to VIII. Sectoral
ducts have a similar meaning, except pertaining to the
four parenchymal sectors of the French system. Embryology
The cystic duct refers to the entire ductal structure
communicating between the gallbladder and the main The first signs of the formation of the hepatobiliary
extrahepatic biliary system. If an accessory or anomalous system are noted at approximately the fifth week of
duct joins the cystic duct, the entire length of the duct intrauterine life when an outpouching forms from the
until it joins the primary system is still the cystic duct. ventral surface of the primitive gastrointestinal tract just
Accessory refers to an unusual location of an expected beyond the junction of the foregut and midgut. This out-
structure, such as a duct. The terms anomalous or aber- pouching eventually forms both lobes of the liver, the
rant are essentially synonymous and refer to additional entirety of the biliary tree, and a portion of the pancre-
unexpected variations of structures. For example, a atic head and uncinate process. As the outpouching pro-
segment VI duct joining the cystic duct before its junc- gresses superiorly, it divides into a superior bud that leads
tion with the common hepatic duct would be accessory, to the formation of the liver and an inferior bud which
whereas a large duct of Luschka between the gallbladder forms the gallbladder and common duct. A separate third
and liver parenchyma is anomalous because it does not bud leads to formation of the ventral pancreas. If the infe-
correspond to a specific segment or sector. Because the rior bud progresses too far superiorly, an intrahepatic
amount of duct necessary to drain a portion of liver has gallbladder (usually in the right lobe) may form. The
not been substantially determined on a physiological rotation of the ventral pancreas and the rest of the gas-
level, the term accessory should not connote simply an trointestinal tract brings the junction of the common
alternate route for bile. The gallbladder is determined by bile duct and duodenum onto the posteromedial wall of
the presence of a cystic duct. For example, a septated gall- the duodenum. By the seventh to eighth week of intra-
bladder with only one cystic duct is one gallbladder, uterine life, a lumen has formed within the biliary
whereas multiple cystic ducts associated with blind tree and gallbladder. Bile starts to form in the liver
sacs (e.g., fairly common in cows) refer to multiple and flow through the biliary system after 3 months of
gallbladders. development.1
At the distal end of the biliary system, three terms
are commonly used. Ampulla refers to dilatation of the
biliary system just within the duodenal mucosa. The Intrahepatic Ducts
pancreatic duct may or may not join directly within the
ampulla. The term papilla refers to the small, nipple- The biliary drainage system begins at the
shaped tissue created by the ampulla and its associated hepatocyte/cholangiocyte level where portions of the
muscle fibers that project into the duodenum. The hepatocyte membrane form small channels called canali-
ampullary sphincter refers to a ringlike band of muscle culi. Bile drains from the canaliculi into intrahepatic
76 P.E. Wise and M.D. Holzman

True right and left site of the union. The most typical anatomy has the right
hepatic duct confluence posterior sectoral duct following an almost horizontal
RA course before joining with the anterior duct, which
RA descends more vertically. This junction is usually found
RP LH
above the right branch of the portal vein. In a minority
RP LH
of cases, the right ducts do not all incorporate into one
right hepatic duct. Instead, a right segmental or sectoral
62% duct joins the left hepatic duct and creates a third duct
9%
that seems to join the confluence. The biliary drainage of
the caudate lobe (segment I) varies considerably, but
enters both the right and left hepatic duct systems about
A 80% of the time. In about 15% of cases, the caudate lobe
B
drains only into the left hepatic ductal system and in
RA RA about 5% it drains only into the right hepatic duct.8
As the segmental ducts join to form right and left lobar
RP
LH RP (hepatic) ducts, it is not unusual for 1 to 3 cm of the lobar
LH duct to lie within the hepatic tissue. In about 98% of
cases, the right and left ducts unite in an extrahepatic
22% 7% position. The usual extrahepatic length of each hepatic
duct varies from 0.5 to 1.5 cm. Most often, a shorter extra-
hepatic right duct joins a longer left duct at the level of
the base of the right branch of the portal vein.9 Because
C D of this length discrepancy, the terminal intrahepatic
segment of the left hepatic duct generally is easier to
Figure 11.5. Primary variations of the hepatic duct confluence delineate than the similar segment of the right hepatic
(percentages based on anatomic studies). A. “True” right and duct. This anatomic fact is of considerable importance in
left hepatic duct confluence (62%). B. Triple branch confluence operative procedures in which an additional length of
(9%). C. Right posterior sectoral duct draining into left or
biliary duct is needed for an anastomosis to the intestinal
common hepatic duct (22%). D. Right anterior sectoral duct
tract.10
draining into left or common hepatic duct (7%).
Depending partly upon their extrahepatic length, the
right and left hepatic ducts join at a wide or acute angle,
or even descend parallel to each other for a variable dis-
ducts that follow the segmental anatomy determined pri- tance before their union. Most often they merge about 1
marily by the vascular supply.6 The convergence of canali- cm below the hepatic parenchyma to form the common
culi and proximal ductal systems is called the canal of hepatic duct. The angle at which the right and left ducts
Hering. The smaller ducts unite to form a single channel join is of clinical significance to both the endoscopist and
called the segmental bile duct. The ductal patterns then hepatobiliary surgeon. When viewing the union of the
become more variable as the biliary system travels distal lobar ducts from the level of the common hepatic duct,
from the canaliculi. the right hepatic duct often is a “straight shot” relative to
The right and left hepatic ducts are formed by the con- the more acute angle of the left hepatic duct. For this
fluence of the segmental ducts within the substance of the reason, the endoscopist at endoscopy and the surgeon
liver. The left lobar duct forms in the umbilical fissure during choledochoscopy frequently enter directly into
from the union of ducts from segments II, III, and IV and the right lobe of the liver and have greater difficulty
then passes to the right across the base of segment IV entering the left lobe.
(medial portion of the left lobe, topographical quadrate Changes in the “typical” intrahepatic ductal anatomy
lobe). Although there are numerous segmental variations caused by compensatory enlargement of liver tissue after
in the left ductal system, the left side is less variable at damage or resection of a segment or lobe have been
the level of the confluence than the right ductal system7 known for almost a century. The distorted configuration
(Fig. 11.5). The right hepatic duct drains segments V to of the liver and the tendency of the lobe undergoing
VIII and arises from the junction of the right anterior and hypertrophy to rotate and extend across the midline
posterior sectoral ducts. The early anatomic descriptions causes diagnostic and operative difficulties. Vessels and
of the right anterior and posterior ducts as consistently ducts conform to this spatial lobar rearrangement with
failing to form a single right hepatic duct is probably the following consequences: first, the portal vein lies
inaccurate. These ducts of the right side join each other more superficially and is therefore at risk for being
but are extremely variable with respect to the order and injured; and second, the portal venous branches develop
11. Surgical Anatomy of the Gallbladder, Liver, and Biliary Tree 77

an anterior relationship to the bile ducts, making access Arbitrary definitions divide the gallbladder into a
to these ducts exceedingly difficult. In effect, the hilar fundus, body, infundibulum, and neck. The fundus is the
vascular structures course obliquely anterior while the round, blind end of the gallbladder that usually projects
bile duct goes posteriorly.11 about 1 cm beyond the free edge of the right lobe of the
liver. The top of the fundus is often at the apex of an angle
formed by the right lateral border of the rectus muscle
Common Hepatic Duct and the ninth costal cartilage. In this position it comes
into contact with the anterior peritoneum of the abdom-
The common hepatic duct is the length of biliary duct inal wall. The fundus becomes palpable in the right upper
from the hepatic duct confluence to the cystic duct. The abdominal quadrant with gallbladder distension. Usually
common hepatic duct makes up the left border of the tri- in association with stones or cholestasis, the fundus may
angle of Calot, which becomes important in any discus- become kinked upon itself, an anomaly referred to as a
sion of the laparoscopic cholecystectomy and is therefore Phrygian cap. Grossly this may look like a fungating mass,
described in greater detail in a separate section (follow- but histologically the tissue only contains an abundance
ing). The length of common hepatic duct varies from 1 to of fibrous tissue.
10 cm depending on the location of the junction with the The fundus passes without a demonstrable transition
cystic duct, where it then becomes the common bile into the body, which constitutes the largest segment of the
duct.12 The common hepatic duct at the area of the con- organ. Unless a mesentery is present, the entire superior
fluence is separated anteriorly from the posterior aspect surface of the gallbladder body is closely attached to the
of the quadrate lobe by the “hilar plate.” This structure is visceral surface of the liver over the area of the gallblad-
a fusion of Glisson’s capsule and the connective tissue der bed. This intimate relationship to the visceral surface
surrounding the biliary and vascular elements in this of the liver easily permits direct spread of gallbladder
area, which, when opened, can allow excellent exposure inflammation, infection, or neoplasia into the paren-
to the confluence and common hepatic duct.7 chyma of the liver. This relationship also permits pass-
The common hepatic duct can often be associated with age of a cholecystostomy catheter through the liver
accessory ducts. These accessory hepatic ducts are so parenchyma into the gallbladder without spillage.
common as to be found in up to 20% of people. They are The infundibulum of the gallbladder is the tapering
readily injured at cholecystectomy if they traverse the tri- transitional area between the body and neck of the organ.
angle of Calot. In more than half of the cases in which an It usually appears as a shallow diverticulum, lying close
accessory duct is found, it joins the common hepatic duct to the undersurface of the cystic duct, and occasionally
somewhere along its course. Less frequently, the acces- obscuring the duct from view. It is attached to the right
sory duct joins the cystic duct. In the rarest of instances, lateral surface of the second portion of the duodenum by
it may join a duct in the opposite lobe. The majority of an avascular peritoneal fold called the cholecystoduode-
aberrant ducts are on the right side. True aberrant ducts nal ligament. The free surface of the body and the
(see definitions) are rare. One should have higher suspi- infundibulum of the gallbladder also lie in close approx-
cion for aberrant hepatic ductal anatomy when there imation to the first portion of the duodenum as well as to
appears to be unusual arterial or distal biliary anatomy.13 the hepatic flexure and the right third of the transverse
colon.
The infundibulum of the gallbladder rapidly tapers into
Gallbladder the neck, which may be narrow and curve upon itself in
the form of an “S.” The neck is usually directed superi-
The gallbladder is a pear-shaped, distensible appendage orly and to the left. It narrows into a sometimes poorly
of the extrahepatic biliary system, usually holding 30 to defined constriction at its junction with the cystic duct.
50 ml of bile. It lies in a depression on the inferior, or vis- The transition between the neck and the cystic duct can
ceral, surface of the right lobe of the liver. The position be gradual or abrupt. The neck is quite short, usually 5 to
of the gallbladder marks the boundary of the right and 7 mm.15 An asymmetrical outpouching of the inferior
left hepatic lobes in the American system. The gallblad- surface of the infundibulum known as Hartmann’s pouch
der is attached to the liver by areolar connective tissue lies close to the neck. It can often be used as a point of
that contains multiple small lymphatics and veins. These traction to provide exposure during cholecystectomy, but
lymphatic and veins connect the venous and lymphatic it is occasionally adherent to the cystic duct, making the
systems of the gallbladder with those of the liver. Rarely, operation difficult.1 Hartmann’s pouch may also trap
one or more small accessory bile ducts pass through large gallstones that are unable to enter the neck or cystic
this tissue to enter the gallbladder directly (ducts of duct.7
Luschka).14 In extremely unusual cases, major hepatic Unusual morphologies of the gallbladder including
ducts might even drain directly into the gallbladder. septations or duplications or even agenesis may occa-
78 P.E. Wise and M.D. Holzman

Figure 11.6. Unusual gallbladder morphologies

occasionally encountered during laparoscopy or
laparotomy.

sionally present during laparotomy or laparoscopy (Fig. Generally, the cystic duct is about 4 cm long. The length
11.6). These are all rare anomalies with which the hepa- may vary from 0.5 to 8 cm depending on the site of the
tobiliary specialist should be familiar. A septated gall- gallbladder and the junction with the common hepatic
bladder is by definition a bilobar gallbladder with a single duct. The circumference of the duct varies from 3 to
cystic duct but two fundi. Duplication of the gallbladder 12 mm.17 The mucous membrane that lines the cystic duct
means the presence of two cystic ducts. A double cystic usually has 4 to 10 folds, referred to as the spiral valves
duct draining a unilocular gallbladder has once been of Heister. The valves regulate bile flow, serving to
described. More frequently encountered anomalies of prevent excess distension or collapse of the cystic duct,
the cystic duct and gallbladder are intrahepatic gallblad- particularly as intraductal pressure changes. The valves
ders and a gallbladder within the left lobe of the liver.16 may be extremely tortuous, complicating cannulation
during intraoperative cholangiography.
The cystic duct usually runs dorsally, to the right, and
Cystic Duct inferiorly to the common hepatic duct. The course may
be quite tortuous, mimicking other ducts until dissected.
The cystic duct is the route by which the gallbladder fills As a general rule, the cystic duct joins the right aspect of
and empties its bile. It connects the neck of the gallblad- the common hepatic duct. The cystic duct may (1) join
der to the common hepatic duct. In as many as 10% of the common hepatic duct at various angles; (2) be paral-
cases, a portion of the right hepatic biliary system joins lel to the right side of the common hepatic duct before
the cystic duct before its junction with the common entering it; (3) be dorsal to the common duct and enter
hepatic duct. Past autopsy studies of this anatomy have its dorsal surface; (4) be dorsal to the common duct and
been misleading, and most applicable information comes enter it from the left side; (5) enter the right or left
from recent clinical studies involving cholangiography. hepatic duct directly; or (6) join the common duct just
11. Surgical Anatomy of the Gallbladder, Liver, and Biliary Tree 79

before it enters the posteromedial wall of the duodenum. Bile duct injuries during cholecystectomy most fre-
The mode of entrance of the cystic duct into the common quently occur because of poor exposure of Calot’s
hepatic duct may be angular, parallel, or spiral. The triangle, leading to confusion between the common
angular type occurs in about 80% of people. The angle hepatic or common bile duct and the cystic duct. Similarly,
may vary from a right angle to an acute angle of 10°. With vascular injuries or significant bleeding that can obscure
the parallel type of junction, the two ducts may run along- the dissection can occur if the exposure of this anatomy is
side each other for several centimeters. In such cases, the inadequate. Multiple styles and techniques are outlined in
ducts may be closely adherent and impossible to separate the literature to expand Calot’s triangle to its greatest
without injuring the common bile duct. The complexity is widths and thus improve exposure of the key structures
compounded when a common sheath of dense connec- while attempting to avoid tenting the common duct into
tive tissue encircles the two ducts. In such cases it is con- the area of dissection. In the end, these various means
sidered safest to leave a long cystic duct stump attached are all dependent on repetition and the experience of the
to the common bile duct at the time of cholecystectomy. surgeon to avoid ductal or vascular injuries.21
In the spiral type of junction, which occurs in about 2% Another landmark in this region that can be helpful in
of the population, the cystic duct may pass either ventral identifying the plane of the common bile duct and avoid-
or dorsal to the common hepatic duct before joining it. ing injuries during cholecystectomy is Rouviere’s sulcus,
Spiral cystic ducts may join on any surface of the common identified by Rouviere in 1924 as a 2- to 5-cm sulcus lying
hepatic duct, including the left lateral side.18 anterior to the caudate lobe and running to the right of
The variable site of the union of the hepatic and cystic the liver hilum and usually containing the right portal
ducts determines the length of the common bile duct. If triad. Based on anatomic studies by Couinaud and sup-
this union is low, that is, distal within the porta hepatis ported by subsequent laparoscopic cholecystectomy
near the duodenum, the supraduodenal portion of the studies, this sulcus is identifiable in approximately 75%
common bile duct is very short or even absent. If this is of patients and accurately identifies the plane of the
the case, the cystic and common hepatic ducts run paral- common bile duct as substantiated by cholangiogram.
lel for a considerable length, causing difficulties during Identification of the sulcus requires anterosuperior and
cholecystectomy. The cystic duct may also be very short leftward retraction of the neck of the gallbladder with
or absent, in which case the gallbladder may appear to exposure and dissection of the posterior hepatobiliary tri-
empty directly into the common hepatic duct. angle bounded by the neck of the gallbladder, the liver
surface, and the plane of the sulcus. Dissection main-
tained ventral to the plane of the common bile duct, with
Triangle of Calot and Rouviere’s Sulcus care taken to identify a possible posterior cystic artery
The region known as Calot’s triangle differs today when branch or tortuous hepatic artery, is safe even with
compared to the area described by Calot in 1890 while tenting of the common bile duct.22
he was a medical student. He described in his thesis a tri-
angle bordered by the cystic artery, the cystic duct, and
the common hepatic duct. The area described today as Common Bile Duct
his triangle is the region bounded by the cystic duct,
common (or right) hepatic duct, and inferior border of The junction of the common hepatic duct with the cystic
the liver. The change is thought to have occurred because duct forms the common bile duct. The length of the
of the practical use of the larger triangle that helps to common duct is variable, reported in the adult to be as
frame and identify the cystic artery that lies within it.19 short as 1 cm and as long as 17 cm.23 The upper limit of
Recognition of critical structures and dissection within normal for the diameter of the common bile duct was for-
Calot’s triangle is of great importance during cholecys- merly controversial. Increased use of ultrasonography
tectomy, especially at the apex of the triangle. The apex has now defined the upper limit of normal for common
of the triangle contains the cystic artery, as discussed, as bile duct diameter as 6 mm; the upper limit of normal
well as the right branch of the hepatic artery, 95% of for the entire width of the duct including the walls is
accessory right hepatic arteries, and 90% of accessory bile 8 mm. These measurements are described as the 95%
ducts.1 An anomalous hepatic artery arising from the confidence limits of normal, so one still needs to consider
superior mesenteric trunk (replaced right hepatic artery) normal in the differential of other ductal widths. After
usually courses superiorly in the groove posterolateral cholecystectomy, the normal common bile duct may
to the common bile duct. Therefore, it appears on the dilate to 10 to 12 mm.
medial side of the apex of Calot’s triangle, just behind the Once the common bile duct has formed by the junc-
cystic duct where it is vulnerable to injury during chole- tion of the cystic and common hepatic ducts, it is desig-
cystectomy. Some degree of replacement is thought to nated as the supraduodenal segment of the common bile
occur in up to 10% of patients.20 duct. Subsequently, it becomes the retroduodenal portion
80 P.E. Wise and M.D. Holzman

Figure 11.7. Typical configura-

tions of the union of the common
bile duct and the pancreatic duct:
A. Low union. B. High union.
C. Absence of union.

A Low union B High union C Absence of union

that in turn leads to the pancreatic and eventually the The intraduodenal segment of the common bile duct
intraduodenal segments of the common bile duct. The passes through the duodenal wall tangentially for almost
supraduodenal segment is usually the longest portion of 2 cm. Most of its course lies in a submucosal plane. The
the common duct and lies in the hepatoduodenal liga- classic anatomic position given for the site of penetration
ment. Superior to the first portion of the duodenum, the of the duodenum by the common bile duct is the pos-
common bile duct lies ventral to the epiploic foramen of teromedial wall. Generally, this site is about 7 cm from
Winslow. Classically, a stone in this segment of the the pylorus. The intraduodenal portion of the common
common bile duct was often easily palpated during an bile duct forms the ampulla of Vater, usually as a conse-
open procedure. Multiple lymph nodes also lie close to quence of the junction of the bile duct and major pan-
the supraduodenal portion of the common bile duct. creatic duct. The length of the ampulla varies from 3 to
Most of these are on the portal (posterior) side of the 14 mm, depending to some degree on the location of the
duct. When enlarged, these occasionally may be mistaken junction. This junction forms the ampulla in one of three
for gallstones during palpation. ways. (1) Frequently there is an extraduodenal junction
The retroduodenal segment of the duct varies in length of the two ducts just external to the posteromedial duo-
from 2 to 4.5 cm. It lies dorsal to the middle aspect of the denal wall (high union). In such instances, the two ducts
duodenum and slants obliquely as it runs from the supe- run parallel to one another for a distance of 2 to 10 mm
rior to the inferior duodenal surface. To the left of the before they penetrate the duodenal wall. During this
retroduodenal portion of the duct is the gastroduodenal close extraduodenal association, the lumens of the two
artery. There, the common bile duct is sometimes involved ducts join and form a single lumen entering the wall. (2)
in the inflammatory reaction associated with a posterior During the passage of the closely applied ducts through
duodenal ulcer. The surgeon must also be careful not to the duodenal wall, the septum between the two may be
divide or entrap the common bile duct while transecting lost just at the ampulla (low union); this would form a
or suturing the proximal portion of the duodenum.14 true common channel that would open through a single
The pancreatic segment of the common bile duct is ostium on the major duodenal papilla. (3) In about 20%
related to the head of the pancreas in either of two ways. of cases, the septum between the ducts persists through-
It may be entirely retropancreatic, lying between the pan- out the entire passage. In this case there is no common
creas and areolar tissues of the retroperitoneum; or it channel proximal to the major duodenal papilla, and the
may lie within the substance of the dorsal portion of the two ducts empty by separate ostia (absence of union)25
pancreatic head, covered dorsally by a thin layer of pan- (Fig. 11.7). These three junctions are the most common
creatic tissue. This segment of the common bile duct has types, but there are rare instances when the pancreatic
a gentle convex curve as it descends relatively close to and common bile duct share a long common channel
the descending portion of the duodenum. About halfway before they reach the duodenum to form the ampulla.
along its pancreatic course, the common duct starts to For example, as many as 90% of patients with a type III
curve gently to the right, then quite abruptly turns almost choledochal cyst have a supraduodenal junction of the
90° in the same direction to enter the descending duo- pancreatic and biliary ducts leading to a lengthy single
denum. The superior pancreaticoduodenal branch of common duct.
the gastroduodenal artery crosses this segment of the As the common bile duct proceeds through the duo-
common bile duct. The location of the artery and its mul- denal wall, it narrows markedly. In 50% of cases, it
tiple duodenal and pancreatic branches makes exposure narrows just before emptying into the ampulla. In virtu-
of the common duct in this region challenging.24 ally all patients the ampulla also narrows just before it
11. Surgical Anatomy of the Gallbladder, Liver, and Biliary Tree 81

empties via the major duodenal papilla. These narrow Arterial Supply
areas are the most common sites for stone impaction in
biliary calculus disease. These sites can also appear to The hepatic artery supplies approximately 25% of the
form a ridge between the wide extraduodenal portion of total blood flow to the liver; however, it provides up to
the duct and the narrower intraduodenal segment. This 75% of the oxygenated blood and about 85% to 90% of
ridge is important in the interpretation of endoscopic the blood to the extrahepatic biliary system (Fig. 11.9).
retrograde cholangiopancreatography (ERCPs) and This extrahepatic arterial system does not parallel the
during common duct explorations because it might be portal channels, although the intrahepatic system does.
interpreted as a pathological mass or, unless care is More than 50% of the population has the same hepatic
taken when the intraduodenal junction is probed, a false arterial pattern.29 The hepatic artery arises from the celiac
passage might be created. axis and passes along the upper part of the pancreas
The circular smooth muscle fibers in the ampulla of toward the liver. Posterior and superior to the duodenum
Vater area constitute the sphincter of Oddi, which regu- it gives off the gastroduodenal artery. Within the hepato-
lates flow of bile from the liver into the duodenum (Fig. duodenal ligament, the hepatic artery divides into right
11.8). The sphincter of Oddi consists of three principal and left branches and subsequently into smaller branches
parts. The first part is the sphincter of the choledochus, corresponding to the portal venous system, segmental, or
the group of circular muscle fibers surrounding the intra- subsegmental anatomy. Often a third artery feeds por-
mural and submucosal bile duct that is responsible for tions of segment IV and the right lobe of the liver.
gallbladder filling during fasting. The second portion is Because of abundant collaterals, ligation of the hepatic
the pancreatic sphincter, which is the variable amuscular artery proximal to the gastroduodenal artery fails to
septum between the biliary and pancreatic ducts that damage the liver.
laminates the secretions from these ducts. The final part Ligation of the hepatic artery distal to the gastroduo-
is the ampullary sphincter, which is the most important denal artery occasionally produces hepatic necrosis.
component of the sphincter of Oddi.26 The ampullary Usually, however, this does not result in serious conse-
sphincter includes a layer of longitudinal muscle fibers quences because there are also rich extrinsic collaterals
that helps prevent reflux of intestinal contents into the to the hepatic artery beyond the gastroduodenal artery.
ampulla. Relaxation of the ampullary sphincter also pro- Ligation of the right or left hepatic artery individually
motes reflux into the pancreatic duct.27,28 predictably results in marked elevation of hepatic
enzyme levels but often still without severe clinical
manifestations. A diffuse subcapsular arterial plexus may

common
bile duct

sphincter
choledochus
(bundle of muscle
fibers encircling
sphincter)
sphincter
ampullae
papilla
von vater

pancreatic
duct
Figure 11.8. The ampulla of Vater including papilla,
ampullary sphincter, and union of common bile duct
and pancreatic duct.
82 P.E. Wise and M.D. Holzman

Figure 11.9. Blood supply to the extra-

hepatic biliary tree. The distal portion is
usually supplied by the retroduodenal
RHA artery (RDA) and the proximal portion
LHA by branches from the right and left
hepatic arteries (RHA, LHA). The mid-
portion of the biliary tree is usually
dependent on the marginal anastomotic
hepatic artery artery (MAA) and other fine axially
arranged collaterals between the RDA
9:00 and the RHA.
o'clock 3:00 o'clock artery
artery
common hepatic artery

PSPDA
gastroduodenal artery

contribute significantly to the hepatic arterial collateral most cases, the cystic artery branches near the neck of the
circulation, as well as supply from the celiac, superior gallbladder. If neither a superficial or deep branch of the
mesenteric, and inferior phrenic artery. A recent angio- cystic artery is found near that point, one should suspect
graphic study showed that rich collaterals can also double cystic arteries.
develop in the liver’s suspensory ligaments.30 The blood supply of the common bile duct classically
The most important variations of the hepatic arterial arises from the cystic artery or the posterior superior
system are a right hepatic artery arising from the supe- pancreaticoduodenal artery. Generally, the arterial
rior mesenteric artery and a common hepatic artery vessels supplying the common bile duct are quite small,
arising from a superior mesenteric trunk (“replaced” and easily disrupted. This characteristic, in combination
hepatic artery). Other anomalies include the left hepatic with the great variation in the distribution of the arterial
artery arising from the left gastric artery and the right supply to the common bile duct and the extremely incon-
hepatic artery traveling anterior rather than posterior to sistent anastomotic patterns of the vessels that supply it,
the portal vein. In addition, the right hepatic artery often probably account for the postoperative ischemic sequelae
has a curved extrahepatic course, which may lead to inad- that follow extensive mobilization of long segments of
vertent ligation during cholecystectomy. When significant the duct. Small branches from the cystic artery usually
hepatic arterial branches arise from the superior mesen- nourish the supraduodenal portion of the common bile
teric artery, they usually pass behind and to the right of duct. These vessels also supply the common hepatic duct
the portal vein. and the lower part of the right hepatic duct. If ascending
The gallbladder receives its blood supply from the arterial branches from vessels supplying the lower seg-
cystic artery. The cystic artery usually originates from ments of the common bile duct are not well developed,
the right hepatic artery shortly after it passes beneath the the cystic artery and occasionally the right hepatic artery
common hepatic duct. The site of origin of the cystic will send off one or two descending branches to the first
artery varies greatly, however. The more common varia- part of the duct.
tions are from an aberrant right hepatic artery, left The retroduodenal or second portion of the common
hepatic artery, more proximal hepatic artery, gastroduo- bile duct is usually supplied by four to six branches from
denal, or even another branch of the celiac artery. In the posterior superior pancreaticoduodenal artery as this
about 10% of cases, a double cystic artery is present. In vessel loops around this segment of the common bile
11. Surgical Anatomy of the Gallbladder, Liver, and Biliary Tree 83

duct. One of these branches may ascend to become an Several small veins also normally drain directly from the
accessory cystic artery. The supraduodenal branch of the right lobe into the vena cava. The middle hepatic vein lies
gastroduodenal artery occasionally sends a tiny branch to in the lobar (portal) fissure draining the medial segment
the retroduodenal portion of the duct. Both the anterior of the left lobe and a portion of the anterior segment of
and the posterior superior pancreaticoduodenal arteries the right lobe. The middle hepatic vein joins the left
supply the third and fourth portions of the common duct. hepatic vein in 80% of dissections.32 The exact site of this
These portions of the duct seem to have a better anasto- junction varies considerably. The left hepatic vein pro-
motic arterial pattern than the first and second ductal vides the principal venous drainage of the left lateral
segments. Despite the large variations in the extrinsic segment. In addition, several small veins from the
arterial supply of the common bile duct, there is an intrin- caudate lobe drain inferiorly directly into the vena cava.
sic arterial system that is generally consistent throughout Following thrombosis of the major hepatic veins
the course of the duct. This intrinsic system is a plexus (Budd–Chiari syndrome), these small posterior caudate
formed on the duct that provides two axial vessels, the 3 veins become important in the formation of collateral
o’clock and 9 o’clock arteries, named for their positions drainage. Venous obstruction can also lead to varying
relative to a cross section of the duct.31 degrees of biliary varices.
There is no constant, single major venous trunk of the
gallbladder. Venous return from the gallbladder occurs in
Venous Drainage multiple directions, via multiple small vessels running
directly into the liver bed or toward the common duct.
Most of the hepatic venous effluent drains into the three Venous drainage from the superior portion of the
major hepatic veins (right, middle, and left) (Fig. 11.10). common bile duct ascends along the surface of the
Each of the three has only a short extrahepatic segment common duct and the hepatic and cystic ducts. It enters
before draining into the inferior vena cava. These short the liver directly rather than by joining branches of the
extrahepatic segments make surgical accessibility diffi- portal vein. The venous drainage from the inferior portion
cult, particularly for control of traumatic bleeding. The of the common bile duct, however, flows into small radi-
right hepatic vein, the largest of the three, provides the cals that directly enter the portal vein. The ventral surface
principal drainage for the right lobe of the liver. The main of the common duct is marked by a constant ascending
trunk of the right hepatic vein follows an intrasegmental vein that can become a hindrance if bleeding from this
plane between the anterior and posterior segments. vessel cannot be controlled during duct surgery.

Middle Caudate
Right
hepatic lobe vein
hepatic
vein vein Left
hepatic
IVC vein

Left portal
Figure 11.10. Schematic representation of vein Paraumbilicalis segment
the hepatic veins and their proximity to the of left portal vein
Right Portal
portal venous system in the liver. IVC, infe- portal vein
rior vena cava. vein
84 P.E. Wise and M.D. Holzman

Lymphatics liver capsule or gallbladder causes pain that is referred to

the right shoulder or scapula via the third and fourth cer-
Hepatic lymph forms in the perisinusoidal spaces of Disse vical nerves. Interruption of the anterior neural plexus
and in the clefts of Mall to drain into larger lymphatics can have various physiological effects including altering
in the porta hepatis33; this subsequently drains into the the accumulation of fat in the liver and changing the lipid
cisterna chyli and eventually into the thoracic duct. composition of hepatic biliary secretions.
Lymphatic vessels lie near the hepatic vein in Glisson’s
capsule and around the bile ducts. Lymphatics also pass
through the diaphragm directly into the thoracic duct. Anatomic Changes from Gallbladder and
Hepatic lymph nodes are found in the porta hepatis, Biliary Pathology
celiac region, and near the inferior vena cava. The classic
porta hepatis lymph node dissection involves a portal In addition to the pathophysiological conditions that
(posterior) as well as a celiac (anterior) dissection. necessitate cholecystectomy, there are multiple diseases
Cirrhosis, venoocclusive disease, and glycogenosis can all that can lead to significant anatomic changes important
lead to lymph vessel dilation. Alterations in the per- for the hepatobiliary surgeon. Many of these conditions
meability of sinusoidal epithelial cells can alter lymph were initially thought to be contraindications to laparo-
flow and protein content, an observation important in the scopic cholecystectomy, but as the laparoscopic surgical
pathogenesis of ascites.34 experience has grown, so have the indications for laparo-
The lymphatic drainage of the gallbladder is into cystic scopic cholecystectomy. These situations include acute
duct nodes near the superior aspect of the cystic duct or and chronic cholecystitis, the Mirizzi syndrome, acute
directly into the hepatic parenchyma. Numerous lym- pancreatitis, cirrhosis, and other less frequently encoun-
phatics traverse the connective tissue between the gall- tered pathological conditions. Because these diseases
bladder and its bed in the liver. This lymphatic (and are addressed in greater detail further in this volume,
adjacent venous) drainage accounts for the high rate of the anatomic changes and their clinical significance are
local invasion seen with gallbladder malignancies. briefly mentioned here.
The lymphatic drainage from the common bile duct Cholecystitis, as the name suggests, is marked by acute
courses superiorly and inferiorly into nodes that lie along and/or chronic forms of inflammation and fibrosing
the course of the duct and finally into a group of 6 to 10 changes of the gallbladder wall. Both acute and chronic
nodes in the porta hepatis. Some lymphatic drainage cholecystitis are notable for significant anatomic changes
from the common duct reaches the deep pancreatic group seen at the time of cholecystectomy. The most significant
of nodes, situated near the origin of the superior mesen- of these findings is the abundance of adhesions sur-
teric artery, but usually the drainage reaches into the rounding the gallbladder. These adhesions of the gall-
deep celiac nodal group. The drainage pattern of the bladder fossa (and sometimes the entire right upper
extrahepatic ductal system accounts for the need to quadrant, often with omental involvement) make the
perform a posterior and deep portal node dissection surgical dissection difficult by obliterating the usually
when dealing with biliary malignancies. An important distinct tissue planes as well as making the anatomy in
degree of drainage also occurs from the ductal confluence the all-important triangle of Calot difficult to define.35,36
area directly posteriorly into the caudate lobe. For that At times these adhesions, especially in chronic cholecys-
reason, several hepatobiliary surgeons advocate routine titis, can lead to adherence of the gallbladder to the colon,
caudate lobe resection in conjunction with cholangiocar- small bowel, or even the stomach. Cholecystoenteric,
cinoma resection. cholecystocolonic, and cholecystogastric fistulas can form
in these conditions and potentially lead to the rare con-
dition of gallstone ileus. This ileus is described as passage
Neural Supply through a fistula of a large gallstone that would otherwise
be unable to pass into the biliary tree from the gall-
The portal and pericapsular regions harbor a complex bladder with subsequent bowel obstruction resulting
system of nerves of unknown clinical importance. An from stone impaction in the distal ileum or ileocecal
anterior neural plexus consists primarily of sympathetic valve. In addition to the significance of the pathological
fibers derived bilaterally from ganglia T7 to T10 and adhesions, the friability of the gallbladder due to inflam-
synapse in the celiac plexus. Fibers from the right and left matory changes (primarily notable in acute cholecystitis)
vagus nerves also contribute to this plexus. The anterior can make retraction impossible and lead to significant
plexus surrounds the hepatic arteries. A posterior plexus incidental cholecystotomies with peritoneal soiling of bile
that intercommunicates with the anterior plexus lies and stones. Retraction difficulty is also seen in empyema
around the portal vein and bile ducts. The sympathetic with a gallbladder containing pus or in hydrops when the
nerves innervate the hepatic arteries. Distension of the gallbladder distends with mucoid material secondary to
11. Surgical Anatomy of the Gallbladder, Liver, and Biliary Tree 85

outlet obstruction, both necessitating drainage of the cirrhosis.44 Another anatomic change caused by the abnor-
gallbladder before it can be grasped for retraction.37 mal fibrosis and hepatocellular regeneration found in cir-
The Mirizzi syndrome shows similar anatomic changes rhosis is the rigidity of the liver, making retraction of the
due to inflammation as those seen in acute cholecystitis, gallbladder and surrounding tissue exceedingly difficult.
and it often presents such a difficult problem to the Other less common pathophysiological changes of the
laparoscopic surgeon that conversion to open cholecys- gallbladder can cause difficulty during cholecystectomy
tectomy is usually necessary. Mirizzi, an Argentinean as well. Examples of these conditions include gallbladder
surgeon, described this syndrome in 1948 as jaundice diverticula and adenomyomatosis of the gallbladder.
(and sometimes cholangitis) caused by an impacted stone Diverticular disease of the gallbladder, similar to that of
in the gallbladder neck or cystic duct leading to external the colon, includes true and false diverticula. This com-
compression and obstruction of the common hepatic plication can lead to trouble during resection caused by
duct.38 This definition was expanded to two types in the chronic scarring of the diverticulae to surrounding struc-
1980s. Type I is characterized by common hepatic duct tures or even intrahepatic diverticulae, necessitating a
obstruction by external compression (stone, tumor, lym- subtotal cholecystectomy to avoid significant hepatic
phadenopathy, etc.) whereas type II is obstruction due to injury or bleeding.45 Adenomyomatosis also leads to
stone passage through a cholecystocholedochal fistula similar changes of scarring or intrahepatic extensions,
resulting from pressure necrosis between the gallbladder making cholecystectomy challenging. It is an acquired
or cystic duct and common hepatic duct. Both are very disease characterized by localized or diffuse extensions
rare, occurring in 0.7% to 1.4% of all cholecystectomies of gallbladder mucosa into, and often beyond, the mus-
performed, but can have a high occurrence of gallbladder cular layer of the wall. Invaginations of the epithelium
carcinoma (up to 28% of cases).39 The nature of the con- externally lead to Rokitansky–Aschoff sinuses, also seen
dition in both types requires very close proximity of the in diverticular disease of the gallbladder. Adenomy-
gallbladder or cystic duct to the common hepatic duct. omatosis has a known increase in occurrence of gall-
This proximity, in combination with the significant bladder carcinoma46 whereas no such relationship is
inflammatory changes in the triangle of Calot intrinsic to noted with diverticular disease.
the syndrome, makes anatomic differentiation of the
ducts difficult during surgical dissection.40
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