CME Article

Anatomy relevant to cholecystectomy

Sanjay Nagral
Department of GI Surgery, Jaslok Hospital and Research Centre, G Deshmukh Marg, Mumbai, India.

Address for correspondence: Department of GI Surgery, Jaslok Hospital and Research Centre, G Deshmukh Marg, Mumbai – 400026,
India. E-mail: nagral@vsnl.com

Abstract cholecystectomy (LC) as the standard procedure, has

led to an increase in bile duct injuries.[2] This seems
This review discusses anatomical facts that are
partly related to the different anatomical exposure of
of relevance to the performance of a safe
cholecystectomy. Misinterpretation of normal
the area around the gallbladder especially the Calot’s
anatomy and anatomical variations contribute to triangle during the laparoscopic procedure as opposed
the occurrence of major postoperative to the open procedure.
complications like biliary injuries following a
cholecystectomy, the incidence being higher with Hence, it is important for biliary and minimally inva-
laparoscopic cholecystectomy. A look at the basic
sive surgeons to appreciate basic anatomical facts as
anatomy is therefore important for biliary and
minimally invasive surgeons. This includes they apply to the performance of cholecystectomy as
normal anatomy and variations of the biliary well as understand from literature how anatomical dis-
apparatus as well as the arterial supply to the tortions or variations can contribute to complications.
gallbladder. Specific anatomical distortions due This review attempts to address these issues. It is not
to the laparoscopic technique, their contribution
in producing injury and a preventive strategy
an exhaustive description of biliary anatomy but dis-
based on this understanding are discussed. cusses anatomical facts that are of relevance to the
Investigative modalities that may help in performance of a safe cholecystectomy.
assessing anatomy are considered. Newer
insights into the role of anatomic illusions as well BASIC ANATOMY
as the role of a system-based approach to
preventing injuries is also discussed.
Gallbladder
Key words: Anatomy; Biliary; Cholecystectomy;
Gallbladder; Injury; Laparoscopy.
The gallbladder is a pear shaped organ situated in a
fossa on the liver undersurface. It is variable in shape
INTRODUCTION and volume. Normally present at the junction of seg-
ments 4 and 5 (and at the lower limit of the principal
Knowledge of relevant anatomy is important for the plane or Cantlie’s line) its position in relation to the
safe execution of any operative procedure. Specifical- liver may vary. For example, it may be partially or com-
ly, in the context of a cholecystectomy, it has been pletely embedded within the liver parenchyma, the so-
recognized since long that misinterpretation of nor- called ‘intrahepatic’ gallbladder. This may create diffi-
mal anatomy as well as the presence of anatomical var- culties in dissection and may increase the chance of
iations contribute to the occurrence of major postop- intraoperative injury to the liver. Although the main
erative complications especially biliary injuries.[1] Such right pedicle is fairly deep in the liver parenchyma,
injuries in turn can cause significant morbidity and oc- large portal, and hepatic venous branches traverse the
casionally even mortality. They are also one of the com- liver at a depth of around one cm from the gallbladder.
monest causes of litigation against abdominal surgeons Thus, a deep liver tear during the dissection of the
in the developed world. There is now a fair amount of gallbladder off its fossa can occasionally bleed profuse-
data to suggest that the acceptance of laparoscopic ly. Also, during the dissection it may be important to

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Nagral S: Anatomy relevant to cholecystectomy

err on the side of the gallbladder rather than the liver en identity with the bile duct before it is clipped or
parenchyma. ligated.

The gallbladder is divided into a fundus, a body and a The cystic duct joins the gallbladder at the neck and
neck or infundibulum. The ‘Hartmann’s pouch’ an out this angle may be fairly acute. Also the mode of joining
pouching of the wall in the region of the neck is recog- may be smooth tapering or abrupt. On the bile duct
nized more as an outcome of pathology in the form of side its mode of union shows significant variations [Fig-
dilatation or presence of stones.[3] This pouch is varia- ure 1]. Since such variations are not uncommon it may
ble in size but a large Hartmann’s pouch may obscure not be safe to try and dissect the cystic duct to its
the cystic duct and the Calot’s triangle. This may be junction with the bile duct. It is important to remem-
result of plain enlargement or due to adherence to the ber that even in the low insertion variety the cystic
cystic duct or bile duct. Thus a small cystic duct can duct rarely goes behind duodenum and therefore a
get completely hidden and traction on the gallbladder ductal structure passing behind the duodenum is more
can lead to the bile duct looking like the cystic duct. likely to be the bile duct itself. Double cystic ducts are
An exaggerated form of the same process is the ‘Miriz- described but are exceedingly rare and therefore two
zi’s syndrome’ in which a large stone in the Hartmann’s ductal structures entering the gallbladder should always
pouch area is either adherent to or erodes into the be viewed with suspicion. Also the cystic duct does
bile duct. This can create major difficulty during a chole- not have vessels traveling on its surface whereas the
cystectomy. bile duct has such visible vessels.[2]

Although the accessory ducts are discussed separately Cystic artery and right hepatic artery
later in the article the cholecysto-hepatic duct can join The cystic artery is a branch of the right hepatic artery
the gallbladder at any point in its hepatic bed. The (RHA) and is usually given off in the Calot’s triangle. It
exact incidence of such ducts is not well documented has a variable length and enters the gallbladder in the
and in fact some authors question their existence.[3] neck or body area. The course and length of the cystic
Thus, a duct encountered in the gallbladder fossa is artery in the Calot’s triangle is variable. Although clas-
likely to be a small superficial intrahepatic duct and sically the artery traverses the triangle almost in its
can be ligated safely. center, it can occasionally be very close or even lower
than the cystic duct.
Cystic duct
The cystic duct joins the gallbladder to the bile duct It usually gives off an anterior or superficial branch and
and is one of the important structures needing proper a posterior or deep branch. This branching usually takes
identification and division during a standard cholecys-
tectomy. The cystic duct may run a straight or a fairly
convoluted course. Its length is variable and usually
ranges from 2 to 4 cm.[3] Around 20% of cystic ducts
are less than 2 cm. Hence there may be very little space
to put clips or ligatures. True absence of the cystic
duct is extremely rare[3] and if the duct is not seen is
more likely to be hidden. The cystic duct is usually 2–
3 mm wide. It can dilate in the presence of pathology
(stones or passed stones). The normal bile duct is also
around 5 mm and hence can look like a mildly dilated
cystic duct. In general a cystic duct larger than 5 mm
(or the need to use a very large clip to completely
occlude the duct) should arouse a suspicion of mistak- Figure 1: Modes of union of cystic duct with bile duct

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 Nagral S: Anatomy relevant to cholecystectomy

place near the gallbladder. When the point of dissec- patic artery or the left hepatic artery (2–5%) it crosses
tion is very close to the gallbladder as in a LC or the the bile duct anteriorly and may be prone to injury.
branching is proximal, one may have to separately ligate Also the superior mesenteric artery may give off the
the two branches [Figure 2]. Also if the presence of a cystic artery in which case it ascends to the gallblad-
posterior branch is not appreciated it can cause trou- der below the cystic duct. An accessory or replaced
blesome bleeding during posterior dissection. In addi- RHA from superior mesenteric artery which is a varia-
tion the cystic artery gives of direct branches to the tion seen in almost 15% of individuals the RHA courses
cystic duct. These small vessels have been better ap- thru the Calot’s triangle (and therefore nearer the gall-
preciated in the era of LC and need to be divided to bladder) and in turn has a shorter cystic artery.
obtain a length of cystic duct before division.
Accessory and aberrant ducts
The RHA normally courses behind the bile duct and There are a large number of accessory ducts described
joins the right pedicle high up in the Calot’s triangle. It in the biliary drainage network of the liver. However,
may come very close to the gallbladder and the cystic the accessory ducts likely to be encountered during a
duct in the form of the ‘caterpillar’ or ‘Moynihan’s’ hump cholecystectomy are those draining parts of the right
[Figure 3]. Although the incidence of this variation is lobe. These ducts are typically small and course through
variable it seems common enough to merit detailed the Calot’s triangle (and therefore closer to the gall-
description and may be as high as 50%.[3] If such a hump bladder) before they enter the common hepatic duct
is present, the cystic artery in turn is very short. In this separately below the confluence of the right and left
situation the RHA is either liable to be mistakenly iden- duct at variable distances. Sometimes the cystic duct
tified as the cystic artery or torn in attempts to ligate may actually join the accessory duct. Some of the var-
the cystic artery. The ensuing bleeding in turn predis- iations of relevance to cholecystectomy are shown
poses to biliary injury. [Figure 4].

There are a fair number of other arterial variations of These ducts may drain substantial portions of the right
the cystic artery also described [Figure 3]. Many of these lobe of the liver, either one of the sectors (two seg-
are unlikely to cause confusion if the artery is divided ments) or a segment and may in fact be the sole drain-
very close to the gallbladder wall. There is a 2–15% age of that part of the liver in which case they are
incidence of double cystic artery. Therefore it may be more precisely termed as ‘aberrant’ ducts. It has been
occasionally necessary to ligate two arteries to the gall- suggested that most such ducts are aberrant rather than
bladder. When the cystic artery is given off not from accessory[3] in which case it is even more important to
the RHA but from other vessels like the common he- safeguard them. Cholangiographic studies have shown

Figure 2: Anterior and posterior branches of the cystic artery Figure 3: Some variations of the arterial supply to the gallbladder

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that there is almost a 20% incidence of the right anteri- dering structures the most challenging step of a chole-
or or the right posterior ducts joining the common cystectomy. In addition the space may be obscured
hepatic duct separately rather than in the form of a and shrunken by various mechanisms. The left (or me-
right duct. If such a duct is injured it can lead to sub- dial) boundary of the triangle formed by the bile duct
stantial biliary stasis or leak. The size of the duct may is the most important structure, which needs to be
be an indirect indicator of the amount of liver it drains. safeguarded.
It has hence been recommended that in case of injury
if the duct is more than 3 mm it should always be Laparoscopic anatomy
drained into a Roux loop.[3] Alternatively one can per- The advent and popularity of LC has led to a new look
form a cholangiogram through the duct to assess the and insights into biliary anatomy especially of the
amount of liver it drains as well as whether it is acces- Calot’s triangle area and the term ‘laparoscopic anato-
sory or aberrant. With increasing recognition of injury my’ has actually found a place even in anatomy texts.
to such ducts these have now been grouped into sepa- Although a detailed discussion of all the factors pecu-
rate type in the recent Strasberg classification[2] of bile liar to laparoscopy that contribute to an increased in-
duct injuries. cidence of injuries is beyond the purview of this re-
view, the different anatomical ‘laparoscopic view’ of
Calot’s triangle the area around the gallbladder especially the Calot’s
This famous triangle was described as bound by the triangle does contribute to misidentification of struc-
cystic duct, the bile duct and the cystic artery in its tures. The method of retraction during the laparoscopic
original description by Calot in 1891. In its present procedure tends to distort the Calot’s triangle by actu-
interpretation the upper border is formed by the infe- ally flattening it rather than opening it out.[2] Also, the
rior surface of the liver with the other two boundaries reluctance to (or difficulty in) performing a fundus first
being the cystic duct and the bile duct [Figure 5]. Its cholecystectomy during the laparoscopic procedure as
contents usually include the RHA, the cystic artery, the opposed to the open procedure also contributes to
cystic lymph node (of Lund), connective tissue, and the same lack of exposure of the Calot’s triangle. Final-
lymphatics. Occasionally it may contain accessory he- ly, the ‘posterior’ or ‘reverse’ dissection of the Calot’s
patic ducts and arteries as discussed previously. It is triangle, which is popular during an LC, again gives a
this triangular space, which is dissected in a cholecys- different view of the area and since the gallbladder is
tectomy to identify the cystic artery and cystic duct flipped over during this method may lead to further
before ligation and division. In reality, it may be a small anatomical distortion. The Rouviere’s sulcus is a fis-
potential space rather than a large triangle making the sure on the liver between the right lobe and caudate
dissection of its contents without damaging the bor- process and is clearly seen during a LC during the pos-

Figure 4: Accessory bile ducts relevant to cholecystectomy Figure 5: Calot’s triangle

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 Nagral S: Anatomy relevant to cholecystectomy

terior dissection in a majority of patients[4] [Figure 6]. Most cholecystectomies are performed after identifi-
It corresponds to the level of the porta hepatis where cation of gallstone disease on ultrasound examination.
the right pedicle enters the liver. It has hence been Although on occasion an ultrasound examination can
recommended that all dissection be kept to a level predict gross distortions of anatomy like the Mirizzi
above (or anterior) to this sulcus[4] to avoid injury to syndrome, in the usual case it does not throw any light
the bile duct. Also, this being an ‘extrabiliary’ refer- on anatomical relations. Thus knowledge of the spe-
ence point it does not get affected by distortion due cific anatomy in that individual is not available to the
to pathology. Similarly, a clear delineation of the junc- surgeon preoperatively as a routine. If a cholangiogram
tion of the cystic duct with the gallbladder along with in the form of a magnetic resonance cholangio pancre-
the demonstration of a space between the gallbladder atography (MRCP) or an endoscopic retrograde cholan-
and the liver clear of any other structure other than the giopancreatography (ERCP) has been performed for
cystic artery (safety window or critical view) is also some reason, it may reveal anomalies like the pres-
recommended as an essential step to prevent bile duct ence of accessory ducts or a low insertion of cystic
injury[2] [Figure 7]. duct.

Investigations to assess the anatomy Methods to assess anatomy during the surgery are per-
Drawings of the Calot’s triangle from anatomy texts haps more relevant. The first and foremost (and per-
are very different from the anatomy seen during the haps the most reliable) is clean dissection and accu-
performance of a cholecystectomy. In the first place all rate visual identification of the contents of the Calot’s
the structures forming the boundaries of the Calot’s triangle especially the cystic artery and duct. The role
triangle are not seen during surgery as they are cov- of a routine intraoperative cholangiogram in delineat-
ered with tissue. Also, in a significant number of indi- ing biliary anatomy and in turn preventing misidentifi-
viduals since the cholecystectomy is performed for cation has been a subject of a long and intense debate
pathology in the form of cholecystitis the anatomy is amongst biliary surgeons but there is conflicting evi-
obscured by inflammation, edema, adhesions, fibrosis, dence on its value.[2] In reality most biliary surgeons
and presence of stones. do not perform a routine intraoperative cholangiogram
but use it selectively. In any case, unless it is performed
In view of the importance of anatomy and it’s varia- through the gallbladder, once a duct has been opened
tions in injuries caused during cholecystectomy it is for a cholangiogram in case it is the bile duct this actu-
logical to look at the possibility of assessing the anat- ally constitutes a partial injury. Also a cholangiogram
omy accurately with the help of imaging before or dur- may not delineate all aberrant ducts and does not pro-
ing the performance of a cholecystectomy. vide any insight into arterial anatomy.

Figure 6: Rouviere’s sulcus Figure 7: The critical view or safety window

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Recently, there have been sporadic reports of the use used in the aviation and maritime industry.[7]
of newer sophisticated technology to identify biliary
as well as arterial anatomy during the performance of a The number of cholecystectomies, especially LCs, be-
cholecystectomy. This has included the use of laparo- ing performed in India has increased phenomenally in
scopic ultrasound for identification of structures, lapar- the last few years. Although there is no large popula-
oscopic Doppler for identification of arteries and the tion-based data there is some evidence that the inci-
use of an instrument called the tactile sensor probe. dence of biliary injuries is increasing as referral units
Some recent reports describe innovative methods such including ours are treating an increasing number of
as the injection of a dye called methelenum coeruleum patients every year. While there has been a lot of focus
into the gallbladder which gives a blue color to the on technology and technical skills, discussions on anat-
biliary system and the introduction of a small optical omy and it’s relevance in prevention of injuries also
fiber thru ampulla of vater which illuminates the entire deserve space in the future.
biliary tree during the cholecystectomy a procedure
called ‘light cholangiography.’[5] Most of these meth- REFERENCES
ods rely on costly technology, are largely unavailable
and have not been scientifically validated. Thus, it 1. Eisendrath DN. Anomalies of the bile ducts and blood vessels as the
cause of accidents in biliary surgery. JAMA 1918;71:864-7.
seems that presently there is no good alternative to 2. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary
meticulous dissection in a planned manner with pre- injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;
180:101-25.
cise identification of structures before they are divid- 3. Adams DB. The importance of extra hepatic
ed. biliary anatomy in preventing complications at
laparoscopic cholecystectomy. Surg Clin N America 1993;73:861-71.
4. Hugh TB, Kelly MD, Mekisic A. Rouviere’s sulcus; a useful landmark in
Finally, an interesting recent study has shown that ‘ana- laparoscopic cholecystectomy. Br J Surg 1997;84:1253-4.
tomic illusions’ to which everyone is susceptible are 5. Xu F, Xu CG, Xu DZ. A new method of preventing bile duct injury in
the primary cause of bile duct injuries; experience, laparoscopic cholecystectomy. World J Gastroenterol 2004;10:2916-
8.
knowledge, and technical skill by themselves may not 6. Way LW, Stewart L, Gantert W, Liu K, Lee CM, Whang K, Huntyer JG.
be adequate protection against such illusions and the Causes and prevention of laparoscopic bile duct injuries. Analysis of
252 cases from a human Factors and cognitive psychology perspective.
resultant complications.[6] The study also suggests that
Ann Surg 2003;237:460-9.
the current incidence of bile duct injury may be near- 7. Hugh TB. New strategies to prevent laparoscopic bile duct injury-
ing the upper limits of human performance and that surgeons can learn from pilots. Surgery 2002;132:826-35.
the most useful corrective strategy may lie outside the
individual in changes in the processes or technology.
Another similar study recommends that surgeons per- Cite this article as: Nagral S. Anatomy relevant to cholecystectomy. J
Min Access Surg 2005;1:53-8.
forming cholecystectomies should have an intraopera-
Date of submission: 17/04/2005, Date of acceptance: 28/05/2005
tive protocol that is similar to navigation principles

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