This document provides an overview of the surgical anatomy, physiology, investigations, congenital anomalies, diseases, and procedures related to the gallbladder and biliary system. It discusses the anatomy of the gallbladder, cystic duct, common hepatic duct, and common bile duct. It also summarizes the arterial supply, lymphatic drainage, and functions of the gallbladder. Various congenital anomalies, diseases like gallstones, calculus cholecystitis, and tumors are described. Surgical procedures for conditions like cholecystectomy, bile duct obstruction, and strictures are outlined.

1. Dr. SAAD M ATTASH
2022
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2. :
Surgical anatomy
 Gall bladder is pear shaped
structure, 50 ml; capacity, divided
into fundus, body , neck and
infundibulum.
 Cystic duct 3 cm, its mucosa form
valve of Heister, it join the
common hepatic duct to form
common bile duct in 80%.
 Common hepatic ducts, right and
left ducts
 Common bile duct about 7.5 cm,
consist of supraduodenal,
reteoduodenal, infraduodenal
and intraduodenal parts.
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3. Arterial supply: from cystic artery
derived from right hepatic artery.
Lymphatic: to cystic L.N. of Land,
then to porta hepatis and celiac
L.N..
Subserous lymphatic also
connect to subcapsular lymph
channels of the liver directly.
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:Surgical anatomy

4. Physiology:
 Bile consist of 97% water, 1-2% bile salts, 1% bile
pigments, cholesterol and fatty acids.
 Liver excrete bile at a rate of 40 ml/hr.
Functions of gall bladder:
1. Is reservoir of bile.
2. Concentration of bile by absorption of water, Nacl,
Hco3.
3. Secretion of mucous 20 ml/day.
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5. Investigation:
1. Plain x-ray.
2. Oral cholecystogram.
3. I.V. colangiogram.
4. U/S.
5. Radioisotope scan using 99m Tc.
6. CT scan.
7. MRI & MRCP.
8. ERCP.
9. PTC.
10. Preoperative cholangiogram.
11. Choledocoscope.
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6. Congential anomalies:
1. Absence of gall bladder.
2. Floating gall bladder.
3. Double gall bladder.
4. Pharygian cap.
5. Diverticulum of gallbladder
6. Absence of cystic duct.
7. Low insertion of the cystic
duct.
8. Accessory cholecysto-
hepatic duct.
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8. Congential anomalies of the biliary duct:
1. Extra-hepatic biliary atresia:
The duct becomes progressively destroyed by
inflammatory process. Usually the child dies before
the age of 3 years due to liver failure or bleeding.
Clinically: Jaundiced child, progressive pail stool; dark
urine, osteomalasia, clubbing of fingers, prurutis, and
skin xanthomas.
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9. Congential anomalies of the biliary duct:
Differential diagnosis:
 choledochal cyst.
 Inspissated bile syndrome.
 Neonatal hepatitis.
Liver biopsy is essential for diagnosis.
Treatment: by by-pass surgery as Roux en y anastamosis.
Liver transplant may be considered.
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10. Congential anomalies of the biliary duct:
2. Congential dilatation of intrahepatic duct (Caroli's
dieease):
Leads to stasis of bile, stone formation cholangitis.
Treatment is by removal of stones and antibiotics cover.
Lobectomy of the liver may be indicated.
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11. Congential anomalies of the biliary duct:
3. Choledochal cyst: Choledochal cysts are congenital
dilations of the intra and/or extrahepatic biliary
system.
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12. Congential anomalies of the biliary duct:
it causes obstructive jaundice and cholangitis with or without
upper abdominal mass.
Diagnosis is by ultrasound and MRI, MRCP
. It is a premalignant condition so excision with Roux en y
anastamosis is proper treatment.
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13. Trauma to gall bladder: is rare and occur as a result of
penetrating or crush injury. operative injury is perhaps
more common. Presentation is acute abdomen,.
Treatment is cholecystectomy., if there associated bile
duct damage then Roux en y choledochojujenstomy is
indicated.
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14. Torsion of gall bladder: is very rare lead to acute
abdomen, treatment by cholecystectomy.
Limey bile: the gall bladder becomes filled with a
mixture of calcium phosphate and calcium carbonate
and appear on plain radiograph, due to gradual
obstruction of the cystic or common bile ducts as in
chronic pancreatitis or carcinoma of pancreas.
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15. 15

16. GALL STONES
 Gall stones are the most common biliary pathology. More than
85% are asymptomatic.
Incidence
10-15% of adult population in the USA has gallstone
600000 cholecystectomy/year in USA
85%of gall stone is asymptomatic
1-4% per year of asymptomatic become
symptomatic
Types of stones:
1. Cholesterol stone.
2. Pigmented stone.
3. Mixed stone. 90% 16

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18. GALL STONES
AETIOLOGY
A- cholesterol and mixed
1- disturbed bile salt, cholesterol, phospholipid concentration.
normally bile salt/phospholipid is 25/1 .this in one hand and
cholesterol concentration in other hand affect the cholesterol
solubility.
when bile supersaturated with cholesterol ,or bile salt decrease
lead cholesterol crystal to nucleate and formation of stone
this occur in malabsorption of bile salt ,liver disease, estrogen,
obesity, high fatty diet
2- stasis of bile ,female hormone, vagatomy, D.M.
B-pigmented stone: Hemolytic anemia
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19. GALL STONES
Effect and complications of stones:
 85-90% are asymptomatic.
 In the gall bladder: silent, acute, chronic cholecystitis,
gangrene, perforation, empyema, mucocele,
carcinoma.
 In the bile duct: obstructive jaundice, cholangitis,
acute pancreatitis.
 In the intestine: acute intestinal obstruction (gall
stone ileus).
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20. CALCULUS CHOLECYSTITIS:
 May be acute or chronic calculus type
Clinical features: pain, right subcostal radiating to the
back and shoulder may be left sided or epigastric,
increased after meal, intermittent or progressive with
or without nausea, vomiting, fever and abdominal
mass, the side may be tender or feature of pertonitis in
complicated cases, jaundice may be absent or present.
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21. CALCULUS CHOLECYSTITIS:
Differential diagnosis:
1. Appendicitis.
2. Perforated peptic ulcer.
3. Acute pancreatitis.
4. Myocardial infraction.
5. Basal pneumonia.
6. Right pyelonephritis.
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22. CALCULUS CHOLECYSTITIS:
Investigations:
1. Ultrasound.
2. Liver function test.
3. Serum-amylase.
4. Chest X-ray.
5. ECG.
6. Urine examination and
cluture.
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23. CALCULUS CHOLECYSTITIS:
Treatment:
1. Conservative: 90% will resolve by conservative
treatment and includes:
N.G. tube, I.V.F., analgesia, and antibiotics.
Subsequent management depend on response to
treatment. If no response or if the diagnosis is not
certain then surgery is indicated.
1. Surgery (early cholecystectomy within 2-3 days) by
open or laparoscopic operation.
2. Late surgery.
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24. Cholecystectomy ; is surgical
removal of gall bladder

Indications:

1-ch. Cholecystitis

2-acute cholecystitis

3-acute acalcalus cholecystitis

4-mucocele

5-empyaema

6-ca. of g.b.

7-stone in CBD

8-asymptomatic gall stone :

- in DM,

- possibility of ca. in g. b.,

- in case of isolation from medical serves
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26. Complication of cholecystectomy
A-general complication
B-specific complication
1-haemorrage
2-biliary leakage
3-sub-phrenic bile, or pus
4-jaundice
- halothane
- missed stone in CBD
- injury of CBD
5-postcholecystectomy syndrome
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27. 
5-postcholecystectomy syndrome: 15% have
symptoms after operation, investigation must be
done to exclude stone in the bile duct or cystic
duct stump, or due to operative damage to biliary
tree, investigation are MRCP or ERCP. Treatment
is according to the cause.
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28. Mucocele of gall bladder:
This occurs when the neck of gall bladder is
obstructed by a stone but the content it sterile, the bile
is absorbed and replaced by a mucus secreted by the
gall bladder epithelium, also might occur in tumor
that occlude the cystic duct as cholangiocarcinoma.
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29. Empyema of gall bladder:
The gall bladder appear to be filled with pus, it may be
a sequel of acute cholecystitis or a result of a mucocele
becoming infected.
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30. Acalculus cholecystitis:
1. Acute a calculus cholecystitis: clinical picture are
similar to calculus type, particularly seen in patient
recovering from major surgery, trauma, burns,.
Mortality is about 20%. Oral cholecystogram and
isotope scan are more useful U/S in diagnosis.
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31. CALCULUS CHOLECYSTITIS:
2. Chronic acalculus cholecystitis: include the
following:
Cholecystoses (cholesterosis, polyposis,
adenomyomatosis, and cholecystitis glandularis
profilerance): is uncommon condition affecting the
gall bladder in which there is chronic inflammatory
changes with hyperplasia of all tissue elements.
Treatment is cholecystectomy for symptomatic case.
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32. CALCULUS CHOLECYSTITIS:
Typhoid gall bladder: cause acute cholecystitis, but more
commonly chronic cholecystitis, the patient being
typhoid carrier, the bacteria are excreted with bile.
Treatment is by ampicillin and cholecystectomy.
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33. Cancer of gall bladder : is rare , spread easily by direct
extension into the liver , seeding of the peritoneal cavity
and involvement of the hilar lymphatic and neural
plexuses. Less than 1% of gall bladder operations.
 Present as for gall stones.
 Courvoisiere low
 Diagnosed by U/S, CT scan and biopsy.
 Prognosis is poor.
 Excision in 10% (cholecystectomy), the remainder is
palliative.
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34. BILE DUCTOBSTRUCTION
(CHOLEDOCHOLITHIASIS):
CAUSES:
1. Stone(1ry or 2ry ).
2. Stricture.
3. Malignancy.
Stone in the bile duct:
clinically symptoms
May be asymtomatic
Charcot's triad (fever , pain, obstructive jaundice).
Reynold’s pentad(hepatic encephalopathy: disturbed LOC
+Shock)
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35. BILE DUCT OBSTRUCTION:
1. Investigations : include U/S: Dilated common bile
duct .
2. Abnormal liver function tests especially alkaline
phosphatase.
,MRI and MRCP, ERCP and liver biopsy (if duct not
dilated).
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36. BILE DUCT OBSTRUCTION:
Treatment:
1. Resuscitation and preparation:
2. I.V.F. , Mannitol and antibiotics.
3. ERCP: Endoscopic papillotomy with sphincterotomy
and removal of stone using Dormia basket.
4. If failed: explration of CBD (Lap. Or open)
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37. BILE DUCT OBSTRUCTION:
Indication for choledochotomy in gall bladder
surgery: are
1. Palpable duct stone.
2. Jaundice or history of jaundice or cholangitis.
3. Dilated common bile duct.
4. Abnormal liver function tests especially alkaline
phosphatase.
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38. BILE DUCT OBSTRUCTION:
 Approach are supraduodenalor transduodenal
sphincterotomy ( removal of stone and insertion of T-
tube in common bile duct ).
 Alternative to it is choedochduodenostomy
(anastomosis between common bile duct and
duodenum).
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39. BILE DUCT OBSTRUCTION:
Stricture of the bile duct :
Causes:
1. Benign : as postoperative 80% (trauma as
cholecystectomy, choledochotomy , gastrectomy , hepatic
resection and transplantation) and inflammatory 20% (
as stones , cholangitis , panceatitis , parasites , sclerosing
cholangitis and radiotherapy ).
2. Malignant :
3. Congenital as biliary artesia .
Investigations :
U/S., Cholangigram if T-tube is present .,ERCP.,
PercutaaneousTrashepatic cholangigram.
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41. BILE DUCT OBSTRUCTION:
Treatment :
1. In benign old stricture Roux en y anastomosis .
2. In benign resent stricture either balloon dilatation or
stent.
3. In malignant stricture either by external drainage (
percutaneous stent ) or internal stent drainage via
ERCP .
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42. Primary sclerosing cholangitis: is chronic fibrosing
inflammatory condition of the biliary tree which affect
both intrahepatic and extrahepatic ducts and may
involve gall bladder and pancreas, may pass into a
stage of liver failure, and are suitable candidate for
liver transplant.
Parasitic infestation:
Hydated cyct .
Ascariasis , may lead to stricture , suppurative
cholangitis , liver abscess , empyema of gall bladder .
operation may be necessary.
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43. Tumors of bile ducts:
1. Papillomatosis: multiple low grade papillary
carcinoma and should be treated by
choledochoscopy with obliteration of papillary
lesion.
2. CholangioCarcinoma: more in patient with bile duct
stone, sclerosing cholangitis and ulcerative colitis.
Diagnosis by U/S and CT scan, jaundice could be
relieved by stent. Treatment is by resection if
possible (resection of a lobe of liver and
reconstruction of biliary tree.). prognosis is poor.
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