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Surgical anatomy of biliary tree
- 1. The Biliary Tree ByAshtar Alhamad Under the Professor Süphan Ertürk’s supervision Cerrahpaşa medical school General Surgery department.
- 2. Bile or Gall It’sa dark green to yellowish brown fluid, produced by the liver of most vertebrates, it aids the digestion of lipids in the small intestine. O In humans, bile is produced continuously by the liver (liver bile), and stored and concentrated in the gallbladder. After eating, this stored bile is discharged into the duodenum.
- 3. O The compositionof gallbladder bile is water, bile salts, bilirubin, fats (cholesterol, fatty acids, and lecithin), and inorganic salts.
- 4. O The hepatocytessecrete bile into the bile canaliculi formed between them. The canaliculi drain into the small interlobular biliary ducts and then into large collecting bile ducts of the intrahepatic portal triad, which merge to form the hepatic ducts. The right and left hepatic ducts drain the right and left parts of the liver, respectively. O Shortly after leaving the porta hepatis, these hepatic ducts unite to form the common hepatic duct, which is joined on the right side by the cystic duct to form the bile duct.
- 7. The Gallbladder O itlies in the fossa for the gallbladder on the visceral surface of the liver The gallbladder has three parts • Fundus, Body, and Neck.
- 9. O The bileduct (formerly called the common bile duct) forms by the union of the cystic duct and common hepatic duct O On the left side of the descending part of the duodenum, the bile duct comes into contact with the main pancreatic duct. These ducts run obliquely through the wall of this part of the duodenum, where they unite, forming a dilation, the hepatopancreatic ampulla(Ampulla of Vater) The distal end of the ampulla opens into the duodenum through the major duodenal papilla O The circular muscle around the distal end of the bile duct is thickened to form the sphincter of the bile duct
- 11. Blood Supply O Cysticartery( a branch of right hepatic artery)-gall bladder,cystic duct,hepatic ducts,and upper part of bile duct. • Posterior superior pancreaticoduodenal artery-lower part of bile duct. • Right hepatic artery –minor source of middle part of bile duct.
- 13. Venous drainage O Superiorsurface 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.
- 15. Anatomical Land Marks OIn surgery and especially in cholecystectomy operation there are 5 important land marks that any surgeon must be aware of: O 1. Calot’s triangle O 2. Cystic node of Lund (Mascagni's lymph node) O 3. Hartmann’s pouch O 4. Cystic artery and right hepatic artery O 5. Rouviere’s sulcus
- 16. Calot’s triangle O Alsocalled cystohepatic triangle O It’s bounded on the upper border by inferior surface of liver and on the other two sides by cystic duct and common hepatic duct. Its contents include right hepatic artery, cystic artery, cystic lymph node of Lund. O Its importance: O Dissection of its contents without damaging the bile duct is the most challenging step of laparoscopic cholecystectomy, O In addition, this space may be obscured and shrunken by inflammatory process and adhesion as a result of cholecystitis.
- 18. Lund Lymph node OIt is a guide to the place where cystic duct joins the hepatic duct and is an important structure which needs identification during laparoscopic cholecystectomy.
- 20. Hartmann pouch O isan out-pouching of the wall of the gallbladder, at the junction of the neck of the gallbladder and the cystic duct. O It may be a site where gall stone impacts, which leads to mucocele of gallbladder. So its identification is useful in delineating biliary anatomy while performing a cholecystectomy.
- 22. Rouviere’s sulcus O Itis a fissure on the inferior surface of the liver between the right lobe and caudate process and is clearly seen during posterior dissection during laparoscopic cholecystectomy O Its importance: O The surgeon must draw an imaginary line of safety between this sulcus and the hilar plate, and must avoid any dissection below it.
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