Surgery gallbladder

1. Gallbladders & bile duct:

2. •Gallbladder
• The gallbladder is a hollow, pear-like-shaped organ that lies on the
cystic plate (gallbladder bed) under the surface of the liver.
• Anatomy
• Location
• Intraperitoneal organ
• Size and volume
• Length: 7–10 cm
• Width: 2.5 cm (at its widest point)
• Volume: 30–50 mL under normal conditions
• Can hold up to 300 mL if the cystic duct is obstructed

3. •Composition/structure
• Surface:
• Inferior or peritoneal.
• Superior or hepatic
• Fundus
• Body
• Infundibulum
• Narrow portion of the body that is continuous with the neck of the
gallbladder
• Neck
• Connects to the cystic duct → common hepatic duct → common bile
duct.
• Most common site of gallstone impaction

4. • biliary duct:
• Common hepatic duct
• The right and left hepatic ducts form the
common hepatic duct.
• Length : 4cm & 4mm diameter
• Cystic duct :Length: completely different.
• spirally-spiral valve of Heister

5. • •Common bile duct:
• 7-11 cm long , 5-10 mm in diameter. The
common bile duct is formed by Common
hepatic duct + Cystic duct
• 4 parts:
• 1- Supraduodenal about 2,5 cm long ,
• 2- Retroduodenal,
• 3- infraduodenal
• 4- and intraduodenal.
• 70% case Connects with the main pancreatic
duct extra wall of duodenum
• 2o% case the Connects with the main
pancreatic duct the wall of duodenum the
summit of major duodenal papilla.

6. •Arterial blood supply
• Gallbladder
• Cystic artery
• 90% Branch of the right hepatic artery
• Behind the common bile duct

7. Venous drainage:
• Superior surface of GB drains into
hepatic veins.
• Rest of GB is drained by one or two
cystic veins which enter into right
branch of portal vein.
• Lower part of bile duct drains into
portal vein.

8. Lymphatic drainage:
• Lymphatic drainage:
• Lymph of sub serosa &sub mucosal
• drained to Cystic lymph node
• locate in the neck of GB.
• Sub serosa vessel of GB Connected
• with sub capsular lymph channel of the liver.

9. • Innervation
• innervation
• Sympathetic: via the celiac plexus
• Parasympathetic: vagus nerve
• Sensory: fibers from Rt phrenic nerve

10. Gallbladder surgical physiology:
• Bile is a secretion produced by the liver and stored in the gallbladder
that aids in digestion, neutralization of gastric acid, fat absorption,
and excretion of bilirubin and cholesterol.
• Bile composition:
• Bile is mainly composed of
• water 97%,
• bile salts 1-2%,
• bile pigments ,cholesterol & fatty acid 1%.
• Secretion of bile by liver 40ml/hr.

11. Continue:
• The effect of cholecystokinin on the
gallbladder and the sphincter of Oddi.
• 1-Storage:
• A. During fasting, with the sphincter of
Oddi contracted and the gallbladder
filling.
• B. In response to a meal, the sphincter
of Oddi relaxed and the gallbladder
emptying.

12. Continue:
• 2- concentration of bile:
• Bile is secreted in liver, store and concentrate into the gallbladder,
• Na , Cl , Hco3 absorbed from bile.
• Bile is concentrated ( 5- 10)
• Bile salt , bile pigment , cholesterol and calcium.
• 3- secretion of mucus ( 20 ml in 24 hour )

13. • Congenital anomalies
• Developmentally, a diverticulum grows out from the ventral wall of
the foregut (primitive duodenum), which differentiates into the
hepatic ducts and the liver.
• A lateral bud from this diverticulum becomes the gallbladder and
cystic duct.
• Anomalies are found in 10% of subjects and these are of importance
to the surgeon during cholecystectomy.

14. 1.the gallbladder anomalies:
1. Congenital absence (agenesis) of the gallbladder:
occur 0,03%.
that important when pathologic process effected one are both GB
2. Duplication of the gallbladder: one in 4000.
A- Each GB connect to bile separately
B- shared
3. Left sided gallbladder :
drained to Lt hepatic duct OR CBD.
4. Posterior gallbladder

15. 5.Phrygian Cap
• The Phrygian cap is present in 2–6
per cent of cholecystograms and
may be mistaken for a pathological
• deformity of the organ.
6. Floating gall bladder
• The gall bladder may hang on a
mesentery, which makes it
• liable to undergo torsion

16. Bile duct anomalies:
1.Small ducts may drain directly from the liver into the body of the
gallbladder.
If present, but not recognized at the time of a cholecystectomy, a
bile leak with the accumulation of bile (biloma) may occur in the
abdomen.
2. Absence of the cystic duct:
the gallbladder opening directly into the side of the common
bile duct.

17. 3. choledochal cyst:
Cystic dilatation of the main bile ducts.

18. 4. Congenital biliary atresia :
biliary atresia, one of the causes of neonatal jaundice.
5.A long cystic duct:
travelling alongside the
common hepatic duct to open near the
duodenal orifice.
This occurs in 10% of cases.

19. • DIAGNOSTIC STUDIES
• Blood Tests
• When patients with suspected diseases of the gallbladder or the
• extrahepatic biliary tree are evaluated, a (CBC), LFT are routinely
• requested.
1. An elevated white blood cell (WBC) count may indicate or raise
suspicion of cholecystitis.
2. If associated with an elevation of
 bilirubin,
 alkaline phosphatase,
 and aminotransferase, cholangitis should be suspected.

20. • Blood Tests
3. Cholestasis, an obstruction to bile flow, is characterized by an
elevation of bilirubin (i.e., the conjugated form) and a rise in
alkaline phosphatase.
Serum aminotransferases may be normal or mildly elevated.
4. In patients with biliary colic or chronic cholecystitis, blood tests
will typically be normal.

21. u/s
• Initial investigation of choice in suspected in gallstones disease.
• Non invasive & • Painless
• Accurate identification of gall stones
• Not limited by jaundice or pregnancy
• Allows of GB size ,
• wall thickness ,
• inflammatory changes around GB
• Detects very small stones
• Accurate identification of dilated common bile ducts.

22. Endoscopic ultrasound:
• Endoscope with ultrasound transducer at tip
• Visualizes biliary tree from within stomach & duodenum
• Accurate to detect stones in CBD.

23. Plain radiography:
• X- RAY
1. 10-15 % of GB stones are radio opaque
2. Calcification (porcelain GB)
3. Bile lime
4. Air in bile duct.

24. IV & Oral cholecystography:
• IV Oral cholecystography
• Once considered the diagnostic procedure of choice for gallstones
• replaced by ultrasonography

25. Radioisotope scan:
• noninvasive evaluation of the liver, gallbladder, bile ducts, and
duodenum
• 99mTechnetium-labeled derivatives of
• iminodiacetic acid (HIDA) are injected IV.
• cleared by the Kupffer cells in the liver,
• and excreted in the bile.
• Uptake by the liver is detected within 10 minutes,
• the gallbladder, the bile ducts, and the duodenum are
• visualized within 60 minutes in fasting subjects

26. Ct scan:
• Computerized tomography:
• test of choice in suspected
• malignancy of the gallbladder,
• the extra hepatic biliary system,
• the tumor staging ,
• extent ,
• metastasis
• & lymph node

27. Percutaneous Transhepatic Cholangiography(PTC)
Intrahepatic bile ducts are accessed percutaneously with a
small needle under fluoroscopic guidance.
a guide wire is passed, and subsequently, a catheter is passed over the
wire .
Through the catheter, a cholangiogram
can be performed and therapeutic
interventions done,
such as biliary drain insertions
and stent placements.
Also tumors & stenosis

28. • MRI(Magnetic resonance Imaging)
• Provides anatomic details of liver, gallbladder, pancreas
• In many centers , MRI is first performed for diagnosis of biliary and
pancreatic duct pathology,

29. • ERCP : Endoscopic Retrograde
• Cholangiopancreatography
• Using a side-viewing endoscope,
• the common bile duct can be
• cannulated and a cholangiogram
• performed using fluoroscopy
• The procedure requires intravenous (IV)
• sedation for the patient.
• The advantages of ERCP include direct visualization of the ampullary
region and direct access to the distal common bile duct, with the
possibility of therapeutic intervention.

30. • CONTINUE…
• The test is rarely needed for uncomplicated gallstone
• disease, but for stones in the common bile duct, in particular,
• when associated with
• obstructive jaundice,
• cholangitis,
• or gallstone pancreatitis,
• ERC is the diagnostic and often therapeutic procedure of choice.
• Once the endoscopic cholangiogram has shown ductal stones,
Sphincterotomy and stone extraction can be performed,

31. • ERCP:
• Complications include:
• Pancreatitis
• Biliary tracts perforation
• Minor bleeding
• & cholangitis

32. Continue: