Chapter 20 Extrahepatic Biliary Tract and Gall Bladder

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  • 8/10/2019 Chapter 20 Extrahepatic Biliary Tract and Gall Bladder


    5/23/2014 Print: Chapter 20. Extr ahepatic Biliary Tract and Gallbladder'%20surgical%20anatomy%20-%202004/Chapter%2020_%20Extrahepatic%20Bili ary%20Tract%2 1/63

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    Skandalakis' Surgical Anatomy > Chapter 20. Extrahepatic Biliary Tract and Gallbladder >


    The anatomic and surgical history of the extrahepatic biliary tract and gallbladder is shown in Table 20-1.

    Table 20-1. Anatomic and Surgical History of the Extrahepatic Biliary Tract and Gallbladder

    Aristotle (384-322 B.C.) Mentioned absence of gallbladder in animals

    Galen (ca. A.D. 130-200) Stated that humans have a single bile duct, or perhaps paired bile ducts

    Berengario da Carpi 1522 Agreed with Galen. Wrote, "Sometimes a man lacks a gallbladder; he is then of infirm health and a shorter life."

    De Laguna 1535 Agreed with Galen

    Vesalius 1543 Did not accept concept of Galen

    Fallopius 1606 Denied concept of Galen

    Bergman 1701 First definite case of absence of human gallbladder

    Vater 1723 First report of dilatation of common bile duct

    Morga gni 1769 Re po rted de forma tio ns of the gallbla dder; ma y ha ve be en firs t to see tors ion of the ga llbladde r

    Home 1813 Described biliary atresia

    Bobbs 1867 Described hydrops of gallbladder and performed first successful removal of gallstones

    Von Wyss 1870 Studied variations of the common bile ductNitze 1877 Introduction of cystoscope

    Calot 1891 Original description of cholecystohepatic triangle (Triangle of Calot)

    Sw ain 1894 Pe rfo rmed firs t s ucces sful ope ratio n for cys tic dila ta tio n o f the bile duct, a chole cys to je junos tomy

    Eppinger 1902 Studied cholestasis

    D v 1903 Firs t des cription of ga llbladde r co mpletely s ubmerge d in the liver s ubs ta nce (intrahe pa tic gallbladde r)

    Yllp 1913 Reported extrahepatic biliary atresia due to embryonic developmental arrest

    Re ich 1918 Produced firs t ro entgenogra phy of bilia ry tree by inje cting bis muth pa ste and pe trola tum into an exte rnal fis tula

    Beall and Jagoda 1921 Obtained incidental opacification of the biliary tract during upper GI series performed with barium and buttermilk

    Ba ke s 1 92 3 Firs t re po rt o f in tra ope ra tive end os co pic vis ua liz atio n o f the bile du cts ; u se d a mpu lla ry d ila to rs wh ich are no w kno wn as Ba ke s'dilators

    Ne ugebauer 1924 Firs t pre operative diagno sis o f cys tic dila ta tio n o f the commo n bile duct

    Boyden 1926 Studied duplication of the gallbladder

    Ladd 1928 First successful repair of biliary atresiaGinzburg and Benjamin;Gabriel

    1930 Simultaneous studies of biliary tract with Lipiodol injections

    Mirizzi 1931 First operative cholangiography

    Boyden 1932 Reviewed reports from 1800-1932 of bile ducts entering the stomach

    Hicken, Best, and Hunt 1936 Performed operative cholangiography through the cystic duct stump

    Babcock 1937 Used cystoscope to visualize interior of gallbladder

    McIver 1941 Visualization of bile duct, showing stone

    Po rche r and Ca ro li 1948 De signed device for o pe ra tive cho langiogra phy

    Mirizzi 1948 Reported syndrome of a long cystic duct with impacted stone (Mirizzi's syndrome)

    Ahrens 1951 First description of intrahepatic biliary atresia

    Mallet-Guy 1952 Attempted to establish operative cholangiography as a routine procedure

    Wild eg an s 1 95 3 In strume nta l in de ve lo pme nt of o bs erva tio n ch ole do ch os co pe an d o pe ra tin g-o bs erva tio n ch ole do ch os co pe

    He ale y a nd Schro y 1953 Studie d intra he pa tic a na to my o f bile ductsBoyden 1957 Described relationship of sphincter of Oddi to common bile duct

    Ka sa i 1 95 7 De scrib ed tre atme nt o f "n on co rre cta ble " ca se s o f bilia ry a tre sia by h ep atic po rto ente ro sto my. Re po rt pu blis he d in Ja pa ne se in1957, in English in 1968.

    Alonso-Lej e t a l. 1959 Presented firs t class ifica tion sys tem for choledochal cys ts (described 3 types)

    Myers et al. 1962 Cinefluorographic observation of the common bile duct

    Kune 1964 Described surgical anatomy of common bile duct

    Kla tskin 1965 Described adenocarcinoma a t hepat ic duct b ifurca tion (Kla tskin tumors) [Altemeier had described same s tructures in 1957]

    Hering 1972 Described the connecting link between bile canaliculi and ductules

    To da ni e t a l. 1 97 7 De ve lo pe d cu rre nt sta nd ard cla ss ifica tio n o f cys tic dila ta tio n o f the co mmo n b ile duct

    Harlaftis et al. 1977 Review ed the literature of gallbladder duplication

    Northover and Terblanche 1978 First description of retroportal artery

    Frimdberg 1978 Performed laparoscopic cholecystotomy in pigs

  • 8/10/2019 Chapter 20 Extrahepatic Biliary Tract and Gall Bladder


    5/23/2014 Print: Chapter 20. Extr ahepatic Biliary Tract and Gallbladder'%20surgical%20anatomy%20-%202004/Chapter%2020_%20Extrahepatic%20Bili ary%20Tract%2 2/63

    Toou i et a . 1982 to1986

    Stu ie no rma a n a no rma unction o sp incter o O i

    Filipi, Mall, and Reosma 1985 Performed first animal laparoscopic cholecystectomy

    Mhe 1985 Successfully treated patients by laparoscopic cholecystectomy

    Mouret 1987 Generally credited with first human laparoscopic cholecystectomy

    Petelim 1991 Performed laparoscopic choledochocholithotomy

    Cotton et al. 1991 Studied risks and benefits of endoscopic sphincterotomy for bile stones in elderly high-risk patients and healthy young patientswith normal-sized ducts1994


    O'Neill 1992 Wrote classic monograph on choledochal cysts

    Hin tz e e t a l. 1 99 7 Su cce ss fu lly tre ate d po st-ga stro je jun os to my pa tie nts end os co pica lly fo r b ilia ry dis ea se

    History table compiled by David A. McClusky III and John E. Skandalakis.


    Cotton PB, Geenen JE, Sherman S, Cunningham JT, Howell D, Carr-Locke DL, Nickl NJ, Hawes RH, Lehman GA, Ferrari A, Slivka A, Lichtenstein DR, Baillie J, Jowell PS, Lail LMEvangelou H, Bosco JJ, Hanson BL, Hoffman BJ, Rahaman SM, Male R. Endoscopic sph incterotomy for stone s by e xperts is s afe, even in you nger patients with normal ducts.

    Ann Surg 1998;227:201-204.

    Davis CJ. A history of endoscop ic surgery. Surg Lapa rosc Endos c 1992;2(1):16-23.

    Diekhoff EJ. Altemeier tumors? [letter] Am J Surg 1993;166:570-571.

    Hintze RE, Adler A, Veltzke W , Abou-Rebyeh H. Endos copic access to the pa pilla of Vater for endos copic retrograde cholangiopancreatography in pa tients with Billroth II orRoux-en-Y gastrojejunostomy. Endoscopy 1997 ;29:68-73.

    Hintze RE, Veltzke W, Adler A, Abou-Rebyeh H. Endo scopic sphincterotomy using an S-shaped sph incterotome in patients w ith Billroth II or Roux-en-Y gastrojejunostomy.Endoscopy 1997;29:74-78.

    LaRusso NF (ed). Gallbladder an d Bile Ducts. Philadelphia: Current Medicine, 1997.

    Nagy AG, Poulin EC, Girotti MJ, Litwin DEM, Mamazza J. History of lapa roscopic surgery. Can J Surg 1992;35:271-274.

    Poppe r H. Vienna and the liver. In: Brunner H, Thaler H (eds). Hepatology: A Festschrift for Hans Poppe r. New York: Raven Press , 1985, pp. 1-14.

    Schein CJ, Stern WZ, Jacobson HG. The Common Bile Duct. Springfield IL: Charles C Thomas, 1966.

    Skandalakis JE, Gray SW. Embryology for Surgeons (2nd ed). Baltimore: Williams & W ilkins, 1994.

    Toouli J (ed). Surgery of the Biliary Tract. New York: Churchill Livingstone, 1993.


    Normal Development

    The genesis of the extrahepatic biliary duct system and gallbladder may, perhaps, be the responsibility of the distal portion of the hepatic diverticulum. By the endof the 4th week, it has produced the cystic duct and gallbladder primordium. The common bile duct and the hepatic ducts may be seen at the beginning of the 5thweek. The solid stage of the ducts takes place during the 5th week. The ducts elongate to reach the liver, progressively forming at this time. Slow ductalrecanalization occurs approximately from the 6th through 12th weeks. Human fetal gallbladder contractility in the second half of pregnancy has been reported,although its physiological role is unknown. 3

    Gallstones are among fetal gallbladder anomalies that have been reported. 4

    Variations and Congenital Anomalies of the Gallbladder

    In an ultrasonographic study of 1823 patients, Senecail et al. 5 found morphologic variations and abnormalities in more than 33% of gallbladders, topographicvariations in approximately 3.5%, and 3 cases of duplication.

    Sites of potential malformations of the extrahepatic biliary tract and common bile duct are shown in Fig. 20-1. Anomalies are shown in Tables 20-2 and 20-3.

    Table 20-2. Anomalies of the Extrahepatic Biliary Ducts and the Gallbladder

    Anomaly Prenatal Age atOnset

    First Appearance Sex ChieflyAffected

    Relative Frequency Remarks

    Extrahepatic biliary atresia Acquired Soon after birth Equal Rare Most likely infectious or environmental; not geneticor congenital

    Variation of