This document provides a historical overview of knowledge and surgical advances related to the gallbladder and biliary tract. It discusses key figures from ancient Greece to the late 19th century who contributed anatomical descriptions and early surgical procedures. Major milestones included the first accounts of gallstones in 1420, first gallstone operation in 1687, and first successful gallstone removal in 1733. The modern era of gallbladder surgery began in 1882 with the first open cholecystectomy.

3.  Circa 200 AD – Galen – the gallbladder
as a subsidiary organ for the liver &
responsible for yellow bile
 Renaissance period – Gallbladder seat
of many emotions (gall)
 1652 - Thomas Bartholin – gallbladder
part of bile tract from liver to intestine
 1654 - Thomas Glisson – formed more
detailed anatomy of liver & biliary tract

4.  1420 - Antonio Benevieni – 1st account of
gallstones
 1687 - Stal Pert Von Der Wiel – 1st operation
on gallstones
 1733 – Jean-Louis Petit -1st successful
removal of gallstones with fistula formation
 1859 – J.L.W. Thudichum – Two stage
cholecystostomy
 July 15, 1867 – Dr John Stough Bobbs –
Single stage cholecystostomy

5.  1630 & 1667 – Zambecarri & Teckoff –
proved the gall bladder not essential to life
 1878 - Theodor Kocher – refined
cholecystostomy procedure
 July 15, 1882 – Dr Langenbuch – 1st open
cholecystectomy
 1886 – cholecystotomy 27% mortality vs 12%
mortality for Langenbuch’s
cholecystectomy – became gold standard
 1940’s – Mirizzi introduced cholangiography
for CBD stones

9.  Gallbladder wall has
no muscularis
mucosa or
submucosa
 Predominantly
columnar epithelial
cells
 Rokitansky-Aschoff
sinuses
 Ducts of Luschka

10. 1.Storage and concentration of
hepatic bile
2.Secretion of water and
electrolytes
3.Empting bile into the common bile
duct
controled by secretin, cholecystokinin
(CCK) and gastrin.

11.  Normal capacity of 40-50 mL
 Liver secretes >600 mL of bile daily
 Greatest absorptive capacity
 Concentrates bile 5-10 fold
 NaCl transport by epithelium is
driving force and water passively
absorbed

12. Characteristic (mEa/L) Hepatic Gallbladder
Na 160 270
K 5 10
Cl 62-112 1-10
HCO3 45 10
Ca 4 25
Water 95-98% 85-90%
Bilirubin 1.5 15
Protein (mg/dL) 250 700
Bile Acids 3-50 290-340
Phospholipids 8 40
Cholesterol (mg/dL) 60-70 350-930
Total Solids -- 125
pH 7.0 - 7.8 6.0 - 7.2

13.  Contraction of ampullary sphincter
(Sphincter of Oddi)
 After meal, sphincter of Oddi relaxes &
CCK released — contraction of
gallbladder
 When stimulated, 50-70% of contents
ejected over 30-40 minutes
 Refills over next 60-90 minutes

15.  10-20% of Europeans
and Americans carry
gallbladder stones
 Majority are
asymptomatic
 Symptoms and severe
complications - 25%
 1-2% of asymptomatic
individuals develop
symptoms per year
 Each year, an estimated
700,000
cholecystectomies (US)
 $6.5 billion (US)

21.  Abdominal plain film
 Ultrasound
› 95-98% sensitive, 98% specific
 Radionuclide scan – hepatobiliary
iminodiacetic acid (HIDA)
› Acute cholecystitis: 94% sensitive, 65-85% specific
› Chronic cholecystitis: 65% sensitive, 6-10%
specific
 CT scan
› 50-70% sensitive
› More expensive
 MRCP
› Cost prohibitive

27.  Recurrent cystic duct obstruction & inflammation
 Presents with biliary colic
 Association with meals present in only 50%
 Symptoms
› Pain duration 1-5 hours (rare >24 hrs or <1 hr)
› Nausea & vomiting present 60-70% of time
› Bloating & belching in 50%
› Fever & jaundice rare
 Exam may be normal unless during attack
 Laboratory values usually normal
 Differentials include: GERD, PUD, IBS, pancreatitis
 Treatment is elective laparoscopic cholecystectomy

29.  Variant of chronic cholecystitis
 lipid-laden inflammatory process
 Marked wall thickening with intramural
nodules visible on CT and US
 Cannot distinguish radiographically from
gallbladder carcinoma

30.  Rare disorder where chronic cholecystitis
causes mural calcification of gallbladder wall
 Cholecystectomy is warranted as there is a 30-
65% risk of underlying gallbladder carcinoma

31.  Large gallstone the obstructs small bowel (distal ileum
at ileocecal valve)
 Fistula between gallbladder and duodenum (can be
colon or stomach)
 Most commonly in elderly (>70) females
 History of gallstone-related symptoms present in only
50%
 Only account for <1% of SBO cases
 <0.1% of those with gallstones will develop
 Up to 25% of SBO in elderly patients who have not
had previous abdominal surgery or have a hernia
 Treat with Ex-lap and enterotomy with removal of
stone. Take back for takedown of biliary-enteric
fistula & cholecystectomy when more stable

33.  Most common in East
Asian population
 Most associated with
biliary strictures,
primary sclerosing
cholangitis,
choledochal cysts &
biliary tract tumors
 Spontaneous in <10%
of cases
 Treatment depends on
location & underlying
condition(s)

34.  7-15% of patients
undergoing
cholecystectomy have
CBD stones
 Findings of jaundice,
lightening of stool & dark
urine
 Fevers & elevated WBC
indicate cholangitis
 Serum Bilirubin has PPV
of 28-50%
 Biliary obstruction may
be partial or transient, so
labs may be normal in
up to 30%

35.  May have overlying pancreatitis (up to 45% of all
cases of pancreatitis)
 Dilated CBD in 58% of patients
 Ultrasound only 60-70% sensitive for CBD stones
 MRCP 95% sensitive & 89% specific
 ERCP Gold Standard
› Can both diagnose and treat 90% of time
› Pancreatitis occurs in up to 5% of Patients
 If unable to remove stone with ERCP (or none
available) need to do laparoscopic or open CBD
exploration
 Stone found in CBD within 2 years of
cholecystectomy is termed retained, >2 years is
recurrent

37.  Rare cause of biliary
duct obstruction
 Large stone
contained within
gallbladder
compresses the CBD
 Local spread of
inflammation from
gallbladder to CBD
may also result in
duct narrowing

38. 
Type I - no fistula present:
 Type IA - presence of
the cystic duct.
 Type IB - jbliteration of
the cystic duct.
 Types II-IV - fistula present:
Type II - defect smaller
than 33% of the CBD
diameter.
Type III - Defect 33-66%
of the CBD diameter.
Type IV - Defect larger
than 66% of the CBD
diameter

40.  Acute bacterial infection of biliary tract
 Most common cause of biliary obstruction as often associated
with choledocholithiasis
 Occurs in 4-7% of ERCP and PTC (Percutaneous transhepatic
cholangiography)
 Other causes of obstruction associated with cholangitis:
› Strictures, neoplasms (rare), chronic pancreatitis, congenital cysts,
duodenal diverticula
 Presentation of fever, RUQ pain, jaundice
› Charcot’s triad
 May also have Hypotension & mental status change
› Reynold’s pentad
 Lab findings: Leukocytosis, elevated alk phos, AST, ALT, Bilirubin
(direct)
 Blood cultures positive 40-50%
 CT scan or Ultrasound can help make diagnosis

41.  Immediate IV antibiotics and fluid
resuscitation
 Biliary decompression necessary
› Endoscopic or percutaneous
› May need open CBD exploration & T-tube
placement (higher mortality)
 Overall mortality 2% (5% with toxic
cholangitis)

42.  Choleststic liver disease characterized by fibrotic
strictures in the intrahepatic and extrahepatic biliary
tree in ABSENCE of any known cause.
 Associated with HLA B8/DR3, IDDM, Graves’
Disease, Sjögren’s syndrome, & Myasthenia gravis
 Clinical presentation highly variable
› Jaundice, pruritus, fatigue, abnormal LFT’s
 Mean age 30-50 years
 Male : female 3:1
 Diagnosis by ERCP
 Median survival after diagnosis 10-12 years
 Primary treatment is liver transplantation

43.  Sclerosing
cholangitis caused
by stones, cholangitis
or operative trauma
termed Secondary
sclerosing cholangitis

44.  Rare congenital
dilation of biliary
tract
 1 : 150,000 incidence
in Western countries
 Much more
common in Japan
 Female : male 8:1
 Most often
diagnosed in
infancy
 Treatment is
resection

45.  80-90% caused by iatrogenic
injuries
 Laparoscopic
cholecystectomy most
common
 Present days to weeks after
surgery
 May be years after surgery as
scar tissue obstructs duct
 Treatment is decompression,
drainage, possible surgical
resection.
 Stenting being used with
increasing frequency
 With ligation of CBD &
strictures, need Roux-en-Y
hepaticojejunostomy

46.  5th most common GI tract malignancy
 2-3 times more common in females
 75% over age 65
 5,000 new cases in US annualy
 Found incidentally in 1% to 3% of
cholecystectomy specimens
 Majority of the time, diagnosed in late
stages with distant mets
 Cholelithiasis present in 75-90% of cases
› Only 0.4% of those with gallstones develop
cancer

47.  Over 90% are adenocarcinoma
› 60% scirrhous, 25% papillary, 15% mucoid
 Squamous cell, oat cell, undifferentiated,
adenosquamous & carcinoid tumors less
common
 Only 10% are correctly diagnosed
preoperatively
 1-3 out of every 100 cholecystectomy
specimens will show carcinoma at pathology
 At diagnosis:
› 25% contained to gallbladder wall
› 35% metastases to regional lymph nodes
› 40% have metastasized to distant sites
 Average survival is 6 months after diagnosis

48.  Initial drainage to
cystic duct node
 Descents along CBD
nodes
 Nodes at posterior
head of pancreas
 Interaortocaval
nodes
 Can also spread by
direct invasion into
liver

49.  Most commonly presents with RUQ pain
 Weight loss, jaundice, palpable mass very late findings
 Many report change in quality or frequency of biliary colic
episodes
 US sensitivity 70-99%
 CT approx 75% sensitive
 MRI 90-99% sensitive

50.  Tumor confined to mucosa or
submucosa (T1a) or to
muscularis (T1b) have overall
5-year survival of 100% & 85%
 Spillage of bile during
cholecystectomy can seed
abdomen
 Invasion beyond muscularis
(T2 & T3) need extended
cholecystectomy with lymph
node dissection
 Stage III has ~15% 5-year
survival
 Stage IV has median survival
of 1-3 months from diagnosis
 Majority of cases, therapy is
palliative
 Chemo & radiation hot been
shown to increase survival
Survival following radical resection
of T2 gallbladder cancer vs simple
cholecystectomy

51.  Uncommon tumor anywhere along intrahepatic or
extrahepatic biliary tree
 60-80% occur at bifurcation
 Most present with obstructive jaundice,
hepatomegaly, palpable gallbladder (Courvoisier’s
sign) or cirrhosis (advanced disease)
 2,500-3,000 new cases in US annualy
 Mean age in 50’s, men & women equal
 Increased risk with choledochal cysts, intrahepatic
stones, Liver flukes, dietary nitrosamines & exposure to
dioxin
 Following biliary-enteric anastomosis, 5% will develop
 Tend to spread by direct extension

52.  Intrahepatic tumors
(Klatskin tumors)treated
like hepatocellular
carcinoma
(hepatectomy)
 Perihilar treated with
resection with local
hepatic resection
 Distal treated like
periampullary tumors with
pancreatoduodenectomy
(Whipple)
 TNM staging

53.  Intrahepatic easily
visualized on CT scan
 Perihilar & distal tumors
difficult to visualize on
US and CT
 ERCP & MRCP have
near equal sensitivity
(85-95%)
 Most patients have
serum Bilirubin >10,
elevated Alk Phos &
CA 19-9

54. Preoperative placement of
stents in hepatic & hilar tumor
Resected Left lobe & hilum
with reconstruction

55.  Long-term survival
highly dependant on
stage & treatment
 For resectable
intrahepatic tumors,
overall 5-year 30-40%
 Resectable peri-hilar
tumors 10-20%
 Resectable distal
tumors 28-45%
 Median survival for all
unresectable tumors is
6-7 months