Gallbladder , vesica biliaris, is a thin-walled hollow organ for the accumulation and concentration of bile, which periodically enters after contraction and relaxation of the gallbladder wall and relaxation of the closures [sphincters]. In addition, the gallbladder regulates and maintains a constant level of bile pressure in the bile ducts. It is pear-shaped and is located on the visceral surface of the liver in its own fossa, fossa vesicae felleae on the lower surface of the liver. Here with the help connective tissue it fuses tightly with the fossa of the bladder. Gallbladder from the side abdominal cavity covered with peritoneum. The length of the gallbladder is from 8 to 14 cm, width - 3-5 cm; content - 40-70 cm3. In the gallbladder there is a fundus, fundus vesicae biliaris; neck, collum vesicae biliaris; and body, corpus vesicae biliaris. The neck of the gallbladder passes into the cystic duct, ductus cysticus. The wall of the gallbladder consists of three layers: mucous, tunica mucosa, muscle, tunica muscularis, and adventitia, tunica adventitia.
Mucous membrane, tunica mucosa, the gallbladder is thin and forms numerous folds; it is lined with high prismatic epithelium with a striped border. In the neck area it forms several spiral folds, plicae spirales (Heisteri). The nuchal-tubular glands are located in the submucosa of the bladder neck.
Muscularis, tunica muscularis, the gallbladder is formed by one circular layer of smooth muscles, which stand out significantly in the cervical area and directly pass into the muscular layer of the cystic duct. In the area of ​​the bladder neck, the muscle elements form the closure [Lutkens sphincter].
The adventitia, tunica adventitia, is built of dense fibrous connective tissue; it contains many thick elastic fibers that form networks.

Topography of the gallbladder

The bottom of the gallbladder is projected onto the anterior abdominal wall between the lateral edge of the rectus abdominis muscle and the edge of the right costal arch, which corresponds to
IX costal cartilage. In relation to the spine, the gallbladder is projected at the level LI-LII, and with a high location - at the level ThXI. and when low - at the LIV level. The lower surface of the gallbladder is adjacent to the anterior wall, pars superior duodeni; the case is adjacent to it by the right bend of the colon, flexura coli dextra; it is covered on top by the right lobe of the liver. The peritoneum covers the gallbladder unevenly. The bottom of the bladder is covered on all sides by the peritoneum, and the body and neck are covered only on three sides (bottom and sides). There are cases when the gallbladder has an independent mesentery (if it is located extrahepatically).

Variants of the relative position of the cystic and joint hepatic duct

There are the following options for the relative position of the cystic and common hepatic duct:- Typical relative position;
- Brief cystic duct;
- Short common hepatic duct;
- The cystic duct crosses the common hepatic duct anteriorly;
- The cystic duct crosses the common hepatic duct posteriorly;
- The cystic duct and the joint hepatic duct are located nearby at some distance;
- Separate flow of the common hepatic and cystic duct into the duodenum (bile passes into the gallbladder through the Luschka ducts).
Sometimes all three ducts empty into the duodenum separately. There are cases where the bile duct connects with an accessory duct. The listed anatomical variants have great importance when analyzing the reasons for the excretion of bile and pancreatic juice into the duodenum and during surgical interventions on the bile ducts.
Blood supply. The gallbladder is supplied with blood from the gallbladder arteries, a. cystica (branch of a. hepatica propria). This artery is of important surgical importance during the operation of removing the gallbladder, holecystectomy. The guideline for finding and dressing it is the Calot triangle (tr. Calot). Its borders: on the right - the cystic duct, ductus cysticus; on the left is the common hepatic duct, ductus hepatis communis, on top is the base of the liver. It contains the own hepatic artery, a.hepatica propria, the gallbladder artery, a. cystica, and the cystic duct lymph node. Venous outflow from the gallbladder is carried out through 3-4 veins located on its sides, which flow into the intrahepatic branches of the portal vein.
Lymphatic vessels. The wall of the gallbladder (mucous and serous membranes) contains networks of lymphatic vessels. The submucosa also contains a plexus of lymphatic capillaries. The capillaries anastomose with the superficial vessels of the liver. Lymph drains into the liver The lymph nodes, nodi lymphatici hepatici, located at the neck of the gallbladder at the porta hepatis and along the common bile duct, as well as in the lymphatic bed of the liver.
Innervation. The gallbladder is innervated from the hepatic nerve plexus, pl. hepaticus, formed by the branches of the abdominal plexus, anterior vagus nerve, phrenic nerves and branches of the gastric nerve plexus.

Extrahepatic bile ducts

The following extrahepatic ducts are distinguished:
- Common hepatic duct, which is formed by the fusion of the right and left hepatic ducts;
- Cystic duct, which drains bile from the gallbladder;
- The common bile duct, which is formed from the fusion of the common hepatic and cystic ducts.
Joint hepatic duct, ductus hepatis communis, - is formed from the fusion of the right and left hepatic duct, ductus hepatis dexter et sinister, in the right half of the portal of the liver, in front of the bifurcation of the portal vein. The length of the common hepatic strait of an adult is 2.5-3.5 cm, diameter - 0.3-0.5 cm. It passes through the hepatoduodenal ligament, lig. hepatoduodenal, connects with the cystic duct, resulting in the formation of the common bile duct, ductus choledochus.
Cystic duct, ductus cysticus, - originates from the neck of the gallbladder. Its length is on average 4.5 cm; diameter - 0.3-0.5 cm. The strait passes from right to left, up and forward, and at an acute angle merges with the general hepatic strait. The muscular layer of the cystic duct consists of two layers - longitudinal and circular. The mucous membrane forms a spiral fold, plica spiralis (Heisteri). The relative position of the cystic duct and the common hepatic duct varies significantly, which should be taken into account during operations on the biliary tract.
Joint bile duct, ductus choledochus, is formed from the confluence of the cystic and common hepatic straits and passes through the hepatoduodenal ligament, lig. hepatoduodenale, to the right of the common hepatic artery. Its length is 6-8 cm. The common bile duct connects to the pancreatic duct and opens to back wall (middle third) in the descending part duodenum on the major duodenal papilla, papilla duodeni major (Vateri). At the junction of the duct, an extension is formed - the hepatic-pancreatic ampulla, ampulla hepatopancreatica. There are several types (variants) of the relationship between the common bile duct and the pancreatic at the places where they flow into the duodenum. The ducts open on the major papilla without forming an ampulla or, uniting, to form an ampulla. The hepatopancreatic ampulla contains a partial or complete septum. There are options when the common bile duct and the accessory pancreatic duct, ductus pancreaticus accesorius, open independently. The presented anatomical variants of the relationship between the common bile duct and the pancreatic are of great importance in cases of violations of the excretion of bile and pancreatic juice into the duodenum.
In the wall of the duct in front of the ampulla there is a closing muscle, m. sphincter ductus choledochi, or sphincter Boyden (PNA), and in the wall of the hepatopancreatic ampulla - the second adductor muscle, m. sphincter ampullae hepatopancriaticae s. sphincter (Oddi).
Contraction of the powerful sphincter Boyden, which limits the preampullary part of the common bile duct, closes the path of bile discharge into the duodenum, as a result of which bile enters the gallbladder through the cystic tract. The fixator muscles are influenced by autonomic innervation and regulate the passage of bile (liver or bladder) and pancreatic juice into the duodenum. Hormones also take part in the regulation of bile excretion. digestive system(cholecystokinin - pancreozymin), which are formed in the mucous membrane of the stomach and colon. Along with anatomical features In the structure of the extrahepatic bile ducts, the sequence of discharge of bile into the duodenum is important. It is known that when the sphincter of the common bile duct relaxes, bile first leaves the gallbladder (vesical bile), and subsequently light bile (liver) enters, which filled bile ducts. The sequence of bile discharge forms the basis of diagnosis and treatment (duodenal intubation) inflammatory processes in the bile ducts. In clinical (surgical) practice, the common bile duct is divided into four parts (segments): supraduodenal (located above the duodenum in the lig. Hepatoduodenal); retroduodenal (located in the upper part of the duodenum, pars superior duodeni); retropancreatic - 2.9 cm (located behind the head of the pancreas, and sometimes in its parenchyma) and intramural (located in the posterior wall, pars descendens duodeni).

X-ray of the gallbladder and bile ducts

Now for study functional state gallbladder and bile duct patency, special artificial research methods are used: cholecystography and cholangiocholecystography (choleography). In this case, contrast agents (iodine compounds: bilitrast, bilignost, biligrafin, etc.). It is administered orally, intravenously, or using a fibrogastroscope, the mouth of the common bile duct is probed through the papilla of Vater to obtain contrast of the ducts. The administration of contrast agents is based on the ability of the liver to secrete iodine-containing compounds introduced into the blood into the bile. This method is called excretory cholecystography. The oral method of examination is based on the ability of the liver and gallbladder to collect and accumulate injected contrast agents.
On radiographs after cholecystography, the position, shape, contours and structure of the gallbladder shadow are studied. To determine the functional state of the gallbladder, its extensibility and motility are studied. For this purpose, its value is compared in the photographs before and after the cholecystokinetic effect.
Cholecystography allows you to identify gallbladder abnormalities (position, number, shape and structure). Anomalies in the position of the gallbladder are varied. It may be located on the lower surface of the left lobe of the liver, in the transverse groove, at the site of the round ligament. The most common anomalies in the shape of the gallbladder are in the form of constrictions and kinks, sometimes in shape, it resembles a “Phrygian cap” (M.D. Seventh).
On radiographs after intravenous excretory cholangiopancreatography (choleography) the position, shape, diameter, contours and structure of the shadow of the internal extrahepatic bile ducts are determined. Subsequently, the period of appearance of contrast bile in the neck of the gallbladder is determined. When choleography, tomography of the bile ducts is used, which makes it possible to clarify the diameter, shape, condition distal section common bile duct and the presence of stones.
During choleography, various anomalies in the position of the bile ducts and cystic duct are observed. The number of bile ducts is subject to fluctuation (L. D. Lindenbraten, 1980).

Ultrasound examination (ultrasound) of the gallbladder

Longitudinal scanning of the gallbladder is carried out at an angle of 20-30° relative to the sagittal axis of the body. Transverse scanning is carried out by moving the scanner from xiphoid process sternum towards the navel. Normally, the gallbladder (longitudinal scanning) appears as a clearly contoured echo-negative formation, free from internal structures. The gallbladder can be pear-shaped, ovoid or cylindrical. It is located in the right upper abdomen, regio hypochondrica. On transverse and oblique scans, the gallbladder has a round or ovoid shape. The bottom of the gallbladder (its widest part) is located anterior and lateral to the neck of the gallbladder.
The neck is directed towards the gate of the liver, that is, back and midway. At the junction of the body and the neck there is a good bend. The size of the gallbladder varies widely: length - from 5 to 12 cm, width - from 2 to 3.5 cm, wall thickness - 2 mm. In children, the bottom of the gallbladder rarely protrudes from under the edge of the liver. In adults and elderly people it can be located 1-4 cm lower, and in older people it can protrude 6 cm (I. S. Petrova, 1965). Ultrasonography of the gallbladder is performed to identify developmental abnormalities and diagnose various diseases(cholelithiasis, empyema, cholesterosis, etc.). According to (David J. Allison et al.), Ultrasonography condition of the gallbladder gives a 90-95% probability.

Computed tomography (CT) of the gallbladder and biliary tract

Computed tomography allows you to differentiate the gallbladder and the bile duct system without prior contrast with radiopaque agents. The gallbladder is visualized as a rounded or oval formation, which is located near the medial edge of the right lobe of the liver, or in the thickness of the parenchyma of the right lobe along its medial edge. The cystic duct appears in fragments, which makes it impossible to clearly determine the place where it flows into the common bile duct. In less than 30% of healthy individuals, partial intrahepatic and extrahepatic bile ducts are detected on CT. Extrahepatic bile ducts on tomograms have a round or oval cross-section with a diameter of 7 mm.
Blood supply The extrahepatic bile ducts are carried out by numerous branches of the hepatic artery proper. Venous outflow occurs from the walls of the ducts into the portal vein.
Lymph flows from the bile ducts through the lymphatic vessels located along the ducts and flows into the hepatic lymph nodes located along the portal vein.
Innervation The biliary tract is carried out by branches of the hepatic plexus, plexus hepaticus.

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Gallbladder, vesica fellea (biliaris), is a sac-shaped reservoir for bile produced in the liver; it has an elongated shape with wide and narrow ends, and the width of the bubble from the bottom to the neck decreases gradually. The length of the gallbladder ranges from 8 to 14 cm, the width is 3-5 cm, the capacity reaches 40-70 cm 3. It has a dark green color and a relatively thin wall.

In the gallbladder, the fundus of the gallbladder, fundus vesicae felleae, is its most distal and wide part; the body of the gallbladder, corpus vesicae felleae, is the middle part and neck of the gallbladder, collum vesicae felleae, the proximal narrow part from which the cystic duct arises. ductus cysticus. The latter, connecting with the common hepatic duct, forms the common bile duct, ductus choledochus.

The gallbladder lies on the visceral surface of the liver in the gallbladder fossa, fossa vesicae felleae, separating the anterior part of the right lobe from the quadrate lobe of the liver. Its bottom is directed forward to the lower edge of the liver in the place where the small notch is located, and protrudes from under it; the neck faces the porta hepatis and lies together with the cystic duct in the duplication of the hepatoduodenal ligament. At the junction of the body of the gallbladder and the neck, a bend is usually formed, so the neck appears to lie at an angle to the body.

The gallbladder, being in the fossa of the gallbladder, is adjacent to it with its upper surface, devoid of peritoneum, and is connected to the fibrous membrane of the liver. Its free surface, facing down into the abdominal cavity, is covered with a serous layer of visceral peritoneum, passing onto the bladder from the adjacent areas of the liver. The gallbladder can be located intraperitoneally and even have a mesentery. Usually, the bottom of the bladder protruding from the liver notch is covered with peritoneum on all sides.

The structure of the gallbladder.

The structure of the gallbladder. The wall of the gallbladder consists of three layers (with the exception of the upper extraperitoneal wall): the serous membrane, tunica serosa vesicae felleae, the muscularis membrane, tunica muscularis vesicae felleae, and the mucous membrane, tunica mucosa vesicae felleae. Under the peritoneum, the wall of the bladder is covered by a thin loose layer of connective tissue - the subserosa of the gallbladder, tela subserosa vesicae felleae; on the extraperitoneal surface it is more developed.

The muscular layer of the gallbladder, tunica muscularis vesicae felleae, is formed by one circular layer of smooth muscle, among which there are also bundles of longitudinally and obliquely arranged fibers. The muscular layer is less pronounced in the fundus and stronger in the cervical region, where it directly passes into the muscular layer of the cystic duct.

The mucous membrane of the gallbladder, tunica mucosa vesicae felleae, is thin and forms numerous folds, plicae tunicae mucosae vesicae felleae, giving it the appearance of a network. In the cervical region, the mucous membrane forms several oblique spiral folds, plicae spirales, running one after the other. The mucous membrane of the gallbladder is lined with single-row epithelium; in the cervical region there are glands in the submucosa.

Topography of the gallbladder.

Topography of the gallbladder. The bottom of the gallbladder is projected on the anterior abdominal wall in the angle formed by the lateral edge of the right rectus abdominis muscle and the edge of the right costal arch, which corresponds to the end of the IX costal cartilage. Syntopically, the lower surface of the gallbladder is adjacent to the anterior wall of the upper part of the duodenum; on the right it is adjacent to the right flexure of the colon.

Often the gallbladder is connected to the duodenum or colon by a peritoneal fold.

Blood supply: from the gallbladder artery, a. cystica, branches of the hepatic artery.

Bile ducts.

There are three extrahepatic bile ducts: the common hepatic duct, ductus hepaticus communis, the cystic duct, ductus cysticus, and the common bile duct, ductus choledochus (biliaris).

The common hepatic duct, ductus hepaticus communis, is formed at the porta hepatis as a result of the fusion of the right and left hepatic ducts, ductus hepaticus dexter et sinister, the latter are formed from the intrahepatic ducts described above. Having descended as part of the hepatoduodenal ligament, the common hepatic duct connects with the cystic duct a duct coming from the gallbladder; This is how the common bile duct, ductus choledochus, appears.

The cystic duct, ductus cysticus, has a length of about 3 cm, its diameter is 3-4 mm; the neck of the bladder forms two bends with the body of the bladder and with the cystic duct. Then, as part of the hepatoduodenal ligament, the duct is directed from top to right down and slightly to the left and usually merges with the common hepatic duct at an acute angle. The muscular layer of the cystic duct is poorly developed, although it contains two layers: longitudinal and circular. Along the cystic duct, its mucous membrane forms a spiral fold, plica spiralis, in several turns.

Common bile duct, ductus choledochus. embedded in the hepatoduodenal ligament. It is a direct continuation of the common hepatic duct. Its length is on average 7-8 cm, sometimes reaching 12 cm. There are four sections of the common bile duct:

1. located above the duodenum;
2. located behind the upper part of the duodenum;
3. lying between the head of the pancreas and the wall of the descending intestine;
4. adjacent to the head of the pancreas and passing obliquely through it to the wall of the duodenum.

The wall of the common bile duct, in contrast to the wall of the common hepatic and cystic ducts, has a more pronounced muscular layer, forming two layers: longitudinal and circular. At a distance of 8-10 mm from the end of the duct, the circular muscle layer is thickened, forming the sphincter of the common bile duct, m. sphincter ductus choledochi. The mucous membrane of the common bile duct does not form folds, with the exception of the distal section, where there are several folds. In the submucosa of the walls of the non-hepatic bile ducts there are mucous glands of the bile ducts, glandulae mucosae biliosae.

The common bile duct connects with the pancreatic duct and flows into a common cavity - the hepatopancreatic ampulla, ampulla hepatopancreatica, which opens into the lumen of the descending part of the duodenum at the top of its major papilla, papilla duodeni major, at a distance of 15 cm from the pylorus of the stomach. The ampoule size can reach 5×12 mm.

The type of entry of the ducts can vary: they can open into the intestine with separate mouths, or one of them can flow into the other.

In area major papilla of the duodenum, the mouth of the ducts is surrounded by a muscle - this is the sphincter of the hepatopancreatic ampulla (sphincter of the ampulla), m. sphincter ampullae hepatopancreaticae (m. sphincter ampulae). In addition to the circular and longitudinal layers, there are separate muscle bundles that form an oblique layer, which unites the sphincter of the ampulla with the sphincter of the common bile duct and with the sphincter of the pancreatic duct.

Topography of the bile ducts. The extrahepatic ducts are located in the hepatoduodenal ligament along with the common hepatic artery, its branches and the portal vein. At the right edge of the ligament is the common bile duct, to the left of it is the common hepatic artery, and deeper than these formations and between them is the portal vein; in addition, between the leaves the ligaments lie lymphatic vessels, nodes and nerves.

The division of the proper hepatic artery into the right and left hepatic branches occurs in the middle of the length of the ligament, and the right hepatic branch, going upward, passes under the common hepatic duct; at the place of their intersection, the gallbladder artery departs from the right hepatic branch, a. cystica, which is directed to the right and upward into the region of the angle (gap) formed by the fusion of the cystic duct with the common hepatic duct. Next, the gallbladder artery passes along the wall of the gallbladder.

Innervation: liver, gall bladder and bile ducts - plexus hepaticus (truncus sympathicus, nn. vagi).

Blood supply: liver - a. hepatica propria, and its branch a. cystica approaches the gallbladder and its ducts. In addition to the artery, the portal of the liver includes v. portae, collecting blood from unpaired organs in the abdominal cavity; passing through the system of intraorgan veins, it leaves the liver through vv. hepaticae. flowing into v. cava inferior. From the gallbladder and its ducts deoxygenated blood flows into the portal vein. Lymph is drained from the liver and gall bladder in nodi lymphatici hepatici, phrenici superior et inferior, lumbales dextra, celiaci, gastrici, pylorici, pancreatoduodenales, anulus lymphaticus cardiae, parasternales.

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Liver and gallbladder, Latin name, functional value, their topography, structure, relationship to the peritoneum.

The liver (hepar) is the largest gland in the human body. It is located in the right hypochondrium and in the epigastric region. The diaphragmatic surface is adjacent to the heart, inferior vena cava, spine, visceral - right kidney, adrenal gland, right flexure of the colon and duodenum. Left lobe The liver is in contact with the stomach and esophagus. The peritoneum covers the liver on almost all sides, except for the gate of the liver, the posterior edge and the transverse groove. The liver lies in the right hypochondrium. On the right, the lower edge of the right lobe crosses the costal arch at the level of the VIII rib. Upper limit on the right along the midclavicular line corresponds to the fifth rib, on the left - the fifth-sixth intercostal space. The gallbladder (vesica fellea, biliaris) is a container where bile accumulates. It is located in the anterior part of the right longitudinal groove of the liver, has a pear-shaped shape. There is a bottom, body and neck. The neck of the gallbladder passes into the cystic duct, which connects to the common hepatic duct. The bottom of the gallbladder is in contact with the parietal peritoneum, the body is in contact with the lower part of the stomach, duodenum and transverse colon.
The wall of the gallbladder consists of mucous membrane, muscular membranes and is covered with peritoneum. liver functions: antitoxic, participation in carbohydrate and fat metabolism, hormones are inactivated in it (adrenaline, norepinephrine, serotonin, etc.). The formation of bile. bile meaning: activates enzymes. suction fatty ones and fat-soluble vitamins, resynthesis of triglycerides., stimulates the secretion of pancreatic and intestinal juices.