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KEY POINTS

Key Points

  • image The physiology of the gallbladder, biliary tree, 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 as described in this chapter.

  • image 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.

  • image Laparoscopic cholecystectomy has been demonstrated to be safe and effective, and it has become the treatment of choice for symptomatic gallstones. Knowledge of the various anatomic anomalies of the cystic duct and artery is critical in guiding the dissection of these structures and avoiding injury to the common bile duct during cholecystectomy.

  • image Common bile duct injuries, although uncommon, can be devastating to patients. Proper exposure of the hepatocystic (Calot’s) triangle to obtain the critical view of safety 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, and patient transfer may be required.

  • image The main risk factor for gallbladder disease in Western countries is cholelithiasis. The main complications include cholecystitis, choledocholithiasis, cholangitis, and biliary pancreatitis. Cholelithiasis is also the major risk factor for the development of gallbladder cancer.

  • image Carcinomas of the gallbladder or bile ducts generally have a poor prognosis because patients usually present late in the disease process and have poor response to chemotherapy and radiation. Surgery offers the best chance for survival and has good long-term outcomes in patients with early-stage disease.

ANATOMY

Gallbladder

The gallbladder is a pear-shaped sac that measures around 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 of fluid. The gallbladder is located in an anatomic fossa on the inferior surface of the liver. Cantle’s line, a vertical plane running from the gallbladder fossa anteriorly to the inferior vena cava (IVC) posteriorly divides the liver into right and left lobes. The gallbladder itself is divided into four anatomic areas: the fundus, the 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 and contains most of the smooth muscle of the organ. The body functions as the main storage area and contains most of the elastic tissue allowing for distention. As the body tapers towards the neck of the gallbladder, a mucosal outpouching is present at the junction of the neck and the cystic duct, known as the infundibulum or Hartmann’s pouch. Beyond this, the neck of the gallbladder lies in the deepest part of the gallbladder fossa and can extend slightly into the free portion of the hepatoduodenal ligament, where it ...

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