Liver, gallbladder and the bile ducts

1. Liver and gallbladder

The liver fills the right upper quadrant under the diaphragm. The gallbladder lies in a fossa on its underside, with its fundus just reaching the liver edge at the tip of the right ninth costal cartilage.

Surgeon’s corner: Murphy’s sign: the inflamed fundus touches your hand under the costal margin when the patient breathes in. The fundus is also where the assistant grasps and pushes the gallbladder up over the liver.

2. Parts of the gallbladder

Fundus, body, infundibulum (Hartmann’s pouch) and neck, which continues as the cystic duct. Stones often impact in Hartmann’s pouch and the neck.

Surgeon’s corner: A stone in Hartmann’s pouch pressing on the common hepatic duct causes jaundice (Mirizzi syndrome). Expect dense adhesions and an unclear anatomy: consider a subtotal cholecystectomy.

3. The bile duct and the portal triad

Right and left hepatic ducts join to form the common hepatic duct; the cystic duct joins it to form the common bile duct, which runs down in the free edge of the lesser omentum, behind the first part of the duodenum and through the head of the pancreas to the ampulla in the second part of the duodenum.

Surgeon’s corner: Pancreatic head cancer blocks the bile duct where it runs through the pancreas: painless jaundice and a palpable gallbladder (Courvoisier’s sign).

4. Calot’s triangle and the critical view of safety

The hepatocystic triangle is bounded by the cystic duct, the common hepatic duct and the underside of the liver. The cystic artery (usually from the right hepatic artery) crosses it. In this model the cystic duct and artery are too small to be shown; picture them between the gallbladder neck and the bile duct.

Surgeon’s corner: Critical view of safety: triangle cleared of fat, lower third of the gallbladder off the liver bed, and only two structures entering the gallbladder. If you cannot get it, stop: cholangiogram, subtotal cholecystectomy or call for help. Then try it in the Surgery mode.