Chapter 32

1. The physiology of the gallbladder and sphincter of Oddi are regulated by a complex interplay of hormones and neuronal inputs designed to coordinate bile release with food consumption. Dysfunctions related to this activity are linked to the development of gallbladder pathologies described in this chapter.

2. In Western countries, the most common type of gallstones are cholesterol stones. The pathogenesis of these stones relates to supersaturation of bile with cholesterol and subsequent precipitation.

3. The main risk factor for gallbladder disease in Western countries is cholelithiasis. The main complications include cholecystitis, choledocholithiasis, cholangitis, and biliary pancreatitis. In addition, cholelithiasis plays the role as the major risk factor for the development of gallbladder cancer.

4. Laparoscopic cholecystectomy has been demonstrated to be a safe and effective alternative to open cholecystectomy and has become the treatment of choice for symptomatic gallstones. Knowledge of the various anatomic anomalies of the cystic duct and artery is helpful in guiding the dissection of these structures as well as avoiding injury to the common bile duct during cholecystectomy.

5. Common bile duct injuries, although uncommon, can be devastating to patients. Proper exposure of Calot’s triangle and careful identification of the anatomic structures are keys to avoiding these injuries. Once a bile duct injury is diagnosed, the best outcomes are seen at large referral centers with experienced biliary surgeons.

6. Carcinoma of the gallbladder and bile duct generally have a poor prognosis because patients usually present late in the disease process and have poor response to chemo and radiation therapies. Surgery offers the best chance for survival and has good long-term survival in patients with early-stage disease.

The gallbladder is a pear-shaped sac, about 7 to 10 cm long, with an average capacity of 30 to 50 mL. When obstructed, the gallbladder can distend markedly and contain up to 300 mL.1 The gallbladder is located in a fossa on the inferior surface of the liver. A line from this fossa to the inferior vena cava divides the liver into right and left liver lobes. The gallbladder is divided into four anatomic areas: the fundus, the corpus (body), the infundibulum, and the neck. The fundus is the rounded, blind end that normally extends 1 to 2 cm beyond the liver’s margin. It contains most of the smooth muscles of the organ, in contrast to the body, which is the main storage area and contains most of the elastic tissue. The body extends from the fundus and tapers into the neck, a funnel-shaped area that connects with the cystic duct. The neck usually follows a gentle curve, the convexity of which may be enlarged to form the infundibulum or Hartmann’s pouch. The neck lies in the deepest part of the gallbladder fossa and extends into the free portion of the hepatoduodenal ligament (Fig. 32-1).

###### Fig. 32-1.

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